Dolorology (PAIN) Encore with Rachel Zoffness

Summary

Ologies with Alie Ward — Dolorology (Pain) Encore with Dr. Rachel Zoffness

Air date: April 22, 2026
Guest: Dr. Rachel Zoffness — Pain Psychologist, UCSF Professor, Author of The Pain Management Workbook and Tell Me Where It Hurts

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Overview

This much-requested encore episode dives deep into the science and lived experience of pain (dolorology), featuring Dr. Rachel Zoffness, a clinical psychologist specializing in pain. With warmth, humor, and immense clarity, Alie and Dr. Zoffness explore what pain is, why it hurts, the notorious “pain scale,” and, most importantly, how our brains and emotions play an often overlooked role in how pain is experienced and managed. After five years, Dr. Zoffness returns with exciting updates and a new book, “Tell Me Where it Hurts.”

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Key Discussion Points

What is Dolorology?

• Definition: “Dolorology” refers to the study of the nature and management of pain. The word comes from Latin (“dolor” = pain).
• Dr. Zoffness admits:

  “The honest answer is since I decided I wanted to be on ologies. I was like, I know there’s a word, because I do pain psychology, which is an ology, but I study pain science and pain neuroscience... and there's a word for pain science, which is dolorology.” ([06:43])

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Pain Scales, Subjectivity, and Why Pain Hurts

• The “out of 10” pain scale is widely used, but subjective:
  • “Sometimes people will say, my pain is a 10 out of 10. And it’ll be something... a healthcare provider will think should not be a 10 out of 10...what’s worse? Can you do anything worse to someone who’s suffering than, say, the number that you gave me isn’t accurate?”
    — Dr. Zoffness ([07:55])
• Pain cannot be objectively measured; it’s based entirely on what the person reports.
  • “There’s absolutely no way to measure pain other than what someone tells you.” ([08:51])

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Dr. Zoffness’ Personal Connection to Pain

• Chronic pain as a child (abdominal) and a severe running injury in adulthood.
• Passion for the intersection of neuroscience, psychology, and real-world application spurred her career.
  • “Pain is never purely physical. It’s also emotional...it’s not located in the body, ultimately it’s produced by the brain.” ([09:42])

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The Biopsychosocial Model of Pain

• Pain is NOT solely a physical phenomenon.
• “Pain is your body’s warning system...it exists to protect you and save your life. But like every system in the human body, the pain system can fail. You can actually have pain without damage...That’s what chronic pain is.” ([18:23])
• Three Domains:
  1. Biological: Tissue damage, genetics, sleep, diet, exercise, etc.
  2. Psychological: Thoughts, emotions, trauma history, coping strategies.
  3. Social: Race/ethnicity, access to care, social support, socioeconomic status.
• Pain always involves all three bubbles.

  “If you’re only focusing on the bio component of pain, you’re actually missing two thirds of the pain problem.” ([20:43])

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Pain is Produced in the Brain

• Phantom limb pain is powerful evidence: people can feel pain in missing limbs, showing pain is a construct of the brain.

  “If you can have excruciating...pain in a leg that isn’t there, that has to mean that pain is produced somewhere else...the brain.” ([26:28])

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Acute vs. Chronic Pain

• Acute pain: Sudden onset, usually signaling tissue damage.
• Chronic pain: Lasts 3+ months, often persists even after injury heals.

  “With chronic pain...your brain has become sensitive to pain. Small bits of sensory input...are interpreted...as very big...your brain is hypersensitive and it’s overreacting and it’s not your fault.” ([37:58])

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“Central Sensitization”

• Chronic pain involves the strengthening (via neuroplasticity) of pain pathways:

  “The more you practice pain over and over...the pain pathway in your brain gets really big and strong.” ([37:08])

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How Medicine & Drugs Treat Pain

• Medications target specific receptors in the brain to block pain signals (e.g., opioids mimic endorphins).
• Over time, opioids can sensitize the brain, potentially making pain worse (opioid-induced hyperalgesia).

  “This is just what research shows—over time, opioids sensitize the brain to pain...” ([33:50])

• Medication can be essential but is just one tool; comprehensive pain management is needed.

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Psychological Strategies for Pain

• Cognitive Behavioral Therapy (CBT): Most evidence-based psychological intervention for pain.
  • “CBT teaches us that how you think affects how you feel emotionally, affects how you feel physically, affects how you behave or act—so round and round in a cycle.” ([47:34])
• Changing behavior, even small actions, can disrupt the “pain cycle.”

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The Pain “Dial”

• Imagining pain as a volume knob in the brain helps explain how pain intensity shifts.
  • Stress and anxiety, negative mood, and focused attention all turn pain “up.”
  • Relaxation, positive emotions, and distraction can turn the pain “down.” ([43:10])

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Agency and Shame in Pain

• Stigma persists in medicine: seeing a psychologist for pain is often seen as implying it’s “all in the head.”
  • “That’s the worst part about being a pain psychologist...everyone who comes to see me believes the message: ‘It’s all in your head’...That’s never true. Pain is always biopsychosocial.” ([55:55])

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The “Pain Recipe”

• Everyone has a unique “pain recipe” — a set of factors that lead to increased or decreased pain (analogous to baking brownies!).
• Understanding your “high pain” and “low pain” recipes can help you make helpful changes.

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Pain in Understudied Populations & New Research

• Dr. Zoffness’s new book includes a dedicated chapter on why pain is more prevalent in women, ethnic minorities, and LGBTQ+ individuals.
• Calls for more inclusive research and safe spaces in healthcare.

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Pain Education is Lacking

• 96% of US/Canadian medical schools have zero dedicated compulsory pain education.
  • “If 96% of our doctors are not learning about pain, who then knows about pain?” ([97:39])

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Notable Quotes & Moments

• “Your pain experience is unique to you.” — Dr. Rachel Zoffness ([08:51])
• “Pain is constructed by the brain, of course, in conjunction with the body.” ([34:55])
• “If you’re not targeting the brain, you are not targeting pain.” ([85:53])
• “The more you practice [a skill], the bigger and stronger those pathways get. Guess what happens when you inadvertently practice pain?” ([37:08])
• “Even small changes—like standing on your porch every day—can begin to break the pain cycle.” ([54:13])
• “Pain is treatable. You do not need to be alone on a pain journey.” ([103:28])

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Listener Q&A Highlights

Redheads and Pain

• Myth: Redheads have different pain tolerances — True! They need more anesthesia (and less opioid), due to a gene affecting pain perception. ([70:31])

Gender & Pain

• Chronic pain rates higher in women. Lack of studies in gender diverse groups.

Spicy Food and Pain

• You can build a “spice tolerance” through graded exposure — this is desensitization at work. ([74:54])

Weather and Migraines

• Lower barometric pressure is associated with increased pain in migraines, fibromyalgia, and arthritis, though mechanisms are still unclear. ([77:18])

Emotional vs. Physical Pain

• Emotional/social pain and physical pain overlap significantly in the brain; acetaminophen can even reduce “social pain.” ([80:32])

Sympathy Pain & Empathic Brains

• Mirror neurons make “sympathy pain” real, especially for highly sensitive people. ([88:34])

Touch as Pain Inhibitor

• Rubbing or touching an injured area gates pain (“gate control theory”). Touch signals reach the brain faster than pain signals and can decrease pain. ([89:57])

Forgetting Childbirth Pain

• After childbirth, the brain is flooded with positive chemicals (oxytocin, dopamine, serotonin, endorphins), which modulates pain memories — “so your brain does this funny trick, but that is not true for many other types of terrible pain.” ([91:41])

Marijuana and Pain

• Cannabis can lower pain volume but is best not relied on as a sole solution — it's one tool among many. ([93:16])

Masochism and Context

• Why pain can be pleasurable for some: context and control are key; voluntary pain is processed differently by the brain. ([95:28])

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Practical Takeaways & Advice

• Understanding pain as biopsychosocial is critical for effective treatment.
• CBT and behavioral activation are proven, practical strategies.
  • Start with small actions: e.g., getting sunlight, brief walks, connecting with others.
  • Journaling and accountability buddies can help maintain progress.
• Pain is treatable; you do not have to suffer alone. Seek pain psychologists, supportive friends, workbooks, and evidence-based approaches.

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Dr. Zoffness’s 2026 Update

• Still teaching at Stanford and UCSF.
• Released her new book: Tell Me Where It Hurts.
• Dedicates a chapter to disparities in pain experience among marginalized groups.
• Advocates for accessible pain care for all, not just the privileged. ([60:23])

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Timestamps for Key Segments

• Pain scales and subjectivity: [07:34]
• Dr. Zoffness’s personal pain story: [07:02]
• Biopsychosocial model explained: [19:56]
• Chronic pain and central sensitization: [37:08]
• CBT for pain cycle: [47:34]
• Sympathy/Empathy Pain: [88:34]
• Gate control theory: [89:57]
• Masochism & pain as pleasure: [95:28]
• Pain education crisis: [97:39]
• Final message: pain is treatable and change happens: [103:28]

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Resources & Recommendations

• Books:
  • The Pain Management Workbook by Dr. Rachel Zoffness
  • Tell Me Where It Hurts by Dr. Rachel Zoffness (2026)
• Organizations:
  • The Trevor Project (Dr. Zoffness’s charity of choice for this episode)
• Follow Dr. Zoffness:
  • Twitter: @DrZoffness
  • Instagram: @doczoff
  • Website: zoffness.com

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Memorable Moment

“When people get better and they get their lives back...they feel like they have power again over their bodies and their lives. That is—I will never do anything else. It's the most addictive thing I've ever done.”
— Dr. Rachel Zoffness ([101:25])

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Final Thoughts

This episode reframes pain as a complex, brain/body/social phenomenon. By providing a compassionate, science-backed approach to understanding and managing pain, Dr. Zoffness and Alie Ward offer hope and agency to anyone who lives with pain—or loves someone who does.

Transcript

[Dr. Rachel Zoffness]

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[Alie Ward]

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[Dr. Rachel Zoffness]

And now T Mobile is available in US Cellular stores. Best mobile network based on analysis by Oogle of speed test intelligence data 2H 2025 bigger network the combination of T Mobile's and US cellular network footprints will enhance the T Mobile network's coverage price guarantee. On talk, text and data exclusions like taxes and fees apply. See t mobile.com for details. Substance use disorder and addiction is so isolating. And so as a black woman in recovery, hope must be loud. It grows louder when you ask for help and you're vulnerable. It is the thread that lets you know that no matter what happens, you will be okay. When we learn the power of hope recovery is possible. Find out [e-mail] brought to you by the National Council for Mental well Being,

[Alie Ward]

Shatterproof and the AD Council so ethology is the study of behavior. One reason why I love traveling with people I love is I get to see them in different settings. Here's what I don't love though. Surprises in a vacation rental. That should be the reliable control in your experiment. That is why you should book your next day on vrbo. When you book a VRBO vacation rental, they have VRBO care. They have 24 hour live support from real human beings. It's included. So if something is not as described or isn't working, VRBO can step in to help make it right. So. So book Today on the VRBO app if you know you VRBO terms apply. See vrbo.com trust for details. Oh hey, it's 2026 and I've been excited for years to reintroduce you to one of our most popular episodes ever. We've been holding this one in our back pocket to bust out again cause this ologist has finally, after much waiting and fanfare, released her first book. It's titled Tell me Where it Hurts. It just came out a few weeks ago and we're gonna link it in the show notes. We're also gonna hear a little updated message from at the break. Fresh hot off a voice note that she sent in this morning. So this is a lovely time travel way to hear what she's up to now. Okay, this episode has helped more people than we'll ever know and probably you and a lot of people you know who might be able to use it. So she's amazing. Let's go. Oh hey, it's that smoothie cup you should have washed yesterday. Alie Ward back with an episode of Ologies. Let's get into it. Dolorology. Dolor means pain in Latin. Dolorology. It's the study of the nature and management of pain. It's a real thing. As it turns out, the folks who study it are pretty fired up about talking about it. And it turns out a lot of listeners are like, I have questions. So this allergist reached out to me, told me that her mission as a neuroscientist is to help people feel better, and I was like, well, well, how the hell can I turn that down? So I happened to be in the Bay Area in October following my new husband's new knee surgery, and after we battled some Friday afternoon traffic, we arrived at this ologist's Oakland office with Los Angeles style punctuality and then we settled into her couch to chat. Pain. Turns out she knows her stuff. She has long brown hair, was wearing knee high boots. She has a very youthful exuberance but a CV that slaps, metaphorically speaking. She is a working pain psychologist and assistant clinical professor at the UCSF School of Medicine. She is on the pain education faculty at Dartmouth. She's the co president of the American association of Pain Psychology. She's a Psychology Today columnist about pain and the author of the the Pain Management Workbook, which might be the best $20 you can ever spend other than Skee Ball, which is also fun. This might be better, but we will talk about all of this in a minute. Plus questions from the [e-mail] Ologies I have never received so many questions for any episode. It's great if you want to submit questions for guests. It costs a dollar a month to join at patreon.com ologies but for $0 you can submit send this episode to someone. You can mention Ologies to a friend or a date, or you can subscribe or rate or leave a review that really helps the podcast. I read a new one each week to prove that I read all of your reviews and here is 2026 me jumping in again with a freshie from Cinder Drag whose recent review this week read I'm a terrible fan. Okay, I've been listening to Ologies since pre Covid. Fast forward to 2026 and I'm still listening but realized I never reviewed despite Allie saying it every episode. Sorry Allie. Cinder Drag. Welcome to both the past and the present in this episode. Anytime is a good time for a review. Thank you for leaving one. Anyone else go for it. It helps so much. Okay. Dolerology. Pain. What is it? Why does it hurt? How much does it hurt? Why do some people have more pain than others? How do pain meds work? Do redheads feel more pain? How long does it take to change your brain? How much pain training doctors have? And is there a better alternative to that placard of miserable emojis that they have on the walls in the hospital? All this and life lessons with pain. Psychologist, researcher, professor, author, mental health advocate, and dologist, Dr. Rachel Zofn. What's your pain scale on a pit scale? 1 to 10?

[Dr. Rachel Zoffness]

4. 3. 4. Not bad.

[Alie Ward]

4. That's kind of a lot.

[Dr. Rachel Zoffness]

3.

[Alie Ward]

No, I'm 3. I'm not doubting you. I'm just saying that sounds painful. Oh, I probably have to buzz something, and I don't know what I have to buzz. I'm just gonna let the doc know that we're downstairs. We're only 44 minutes late.

[Dr. Rachel Zoffness]

Okay.

[Alie Ward]

Okay. This is yours, this is mine. It's been so long since I've gotten to do in person interviews, so. Okay, first thing I'm gonna make you do is if you can say your first and last name and your pronouns.

[Dr. Rachel Zoffness]

I kind of want to sit on the floor. Let me see how we are.

[Alie Ward]

Oh, yeah, no, go for it. No, you can sit on the floor. It's like we're hanging out in a dorm room.

[Dr. Rachel Zoffness]

Rachel Zoffness.

[Alie Ward]

Rachel Zoffness.

[Dr. Rachel Zoffness]

She her.

[Alie Ward]

Got it. Dolorology. It's a thing.

[Dr. Rachel Zoffness]

It's a thing.

[Alie Ward]

Okay. How long have you known this word?

[Dr. Rachel Zoffness]

The honest answer is since I decided I wanted to be on ologies. I'm not kidding. I was like, I know there's a word, because I do pain psychology, which is an ology, but I study pain science and pain neuroscience, which is outside of psychology. And there's a word for pain science, which is dolorology.

[Alie Ward]

What's the worst pain you've ever been in?

[Dr. Rachel Zoffness]

Oh, wow. The worst pain I've ever been in. I had chronic pain as a kid, and I was always. I had, like, constant abdominal pain. But as an adult, I also had a running injury, and it lasted for five years, and I was, like, on the couch for the better part of a year. So that was probably the worst one.

[Alie Ward]

What do people say hurts the most? I've heard kidney stones. I've heard birth. I've heard shingles. I've heard bullet ants. How do psychologists figure it out?

[Dr. Rachel Zoffness]

So the honest answer is this. People are trained to ask people about their pain. On all these pain scales, and there's a lot of pain scales out there, and the most common one is out of 10. What is your pain on a scale of 0 to 10?

[Alie Ward]

Yeah, I just did that to Jared outside for probably the 100th time since his surgery two weeks before. Tee hee.

[Dr. Rachel Zoffness]

And the funny thing is, and it's actually not funny at all, sometimes people will say, my pain is a 10 out of 10. And it will be something that a healthcare provider will think should not be a 10 out of 10. So the healthcare provider will say to the patient, well, imagine someone taking off your arm. That would be a 10 out of 10. So now tell me what your pain number is to try and get that person to lower the number. Like, sort of suggesting to the patient, like, oh, you're exaggerating. But in my mind, what's worse? Can you do anything worse to someone who's suffering than, say, the number that you gave me isn't accurate? The answer is the most annoying answer in science, which is it depends. So for one person post surgical, pain might be a 6 out of 10, and for someone else, it might be a 10 out of 10. So I wouldn't say that there's any one thing that is the worst kind of pain.

[Alie Ward]

That's a good answer. And when people are studying how sharp pain is, how do you even know

[Dr. Rachel Zoffness]

that is all you have? There's absolutely no other way to measure pain other than what someone tells you. So if someone says their pain is 10 out of 10, that's what their pain is. The end. I mean, that's also why it's really hard to compare. Like, you can't compare your pain to my pain. Like, you break your ankle, I break mine. But if you're a 10 out of 10 and I'm a 5 out of 10, it's not like one of us is lying.

[Alie Ward]

Yeah.

[Dr. Rachel Zoffness]

Like, your pain experience is unique to you.

[Alie Ward]

And as a kid, as someone who experienced chronic abdominal pain, which I cannot imagine is fun, and a running injury for five years, were you in a position to choose your career at that point? When you had a running injury, were you like, you know what? I'm going to change my major. When did you decide I'm going to crack this code? Because you are super passionate about this. Yeah. You're like, I looked up the word for this. I wrote a book about this. I want to talk about it.

[Dr. Rachel Zoffness]

Yeah. Yeah.

[Alie Ward]

Where does that passion come from?

[Dr. Rachel Zoffness]

So when I was in college, I knew I wanted to live at the intersection of a bunch of Things like, I was fascinated by neuroscience and psychology and science writing and working with kids and medicine. And I just, I wanted to find this thing that would let me live at the intersection of everything. And I took a course, a neuroscience course in my freshman year at Brown, because I was a nerd. Like to be clear, I was like a library mouse, had no friends in high school. Total, total nerd. And in Neura 1, which is the best class I ever took, they taught us about pain. And it was the thing that seemed to live at the intersection of everything because as I'm sure we're going to talk about, pain is never purely physical. It's also emotional. And it' not located in the body, ultimately it's produced by the brain. So and it's this thing that goes across psychology and medicine. It affects adults, it affects kids. It had affected me as a kid.

[Alie Ward]

So pain is in the brain. Big revelation here. Much more on that in a bit.

[Dr. Rachel Zoffness]

So when I went to do my honors thesis, my mentor, who's a dear human being, who recently, actually not so recently passed from cancer, said to me, there's this researcher here who studies pain, you should see if he'll take you on as a mentee. And he did. And, and under his tutelage I did this long honors thesis on the gate control theory of pain. And I just thought it was so dynamic and fascinating. And you know, everyone has pain at some point in their life, right? And when you're a college student, you're still young, but as an even younger person, I had already struggled with pain. So I was so fascinated by this intersection of all the things.

[Alie Ward]

So Rachel will explain the gait thing theory of pain in more detail later and how essentially kissing an owie does a sweet neurological sleight of hand, kind of like a cool bat mitzvah magician. But in terms of her backstory, Dr. Zoff got her bachelor's from Brown University in brain and behavior, two masters, one in psychology and education from Columbia, one in Clinical psychology from San Diego State, and then her PhD in clinical psychology from University of California, San Diego. Somewhere in there, she took a year long break to teach science at the Bronx Zoo. Because she's rad. Anyway, she became a doctor and as

[Dr. Rachel Zoffness]

a postdoc, after I got my PhD in psychology, I did my postdoc in pain management and it was non pharmacological approaches to pain. And I just went back down that rabbit hole and it was just so interesting to me that there were all these ways of treating pain that don't really get talked about in medicine or at all in psychology. Like if you're a psychologist, you never learn about what we call physical pain. Never. And physicians very rarely get talk about the psychological aspect of pain. So when I did my postdoc, I started doing trainings on pain. I just, I wanted to know everything. I read every book I could get my hand on, literally. I spoke with a million people, I took a million classes. And then I decided that I wanted to start treating pain. And in particular I wanted to work with kids living with pain. When I first started that, I really, I mean I was trained in adult and child psychology, but I felt like in particular teenagers get ignored a lot in medicine. It's just this really messy, weird age. They're not quite children, they're not quite adults. So I want to focus on them. So I went to UCSF and I offered to do some trainings for free on these non farm treatments for pain and how pain works in the brain and in all these departments, for some reason, they let me come and give a talk to their physicians. Before I knew it, my practice was full of kids living with chronic pain. Yeah, but Alie Ward, the first, like one of the first kids they sent me. Can I tell you a story?

[Alie Ward]

Yeah, yeah, that's what I'm here for.

[Dr. Rachel Zoffness]

One of the first kids they sent me was a kid who had been in bed for like four years with chronic pain. Yeah, he had chronic migraine, chronic body pain, like diffuse amplified body pain. He had been on about 40 medications, including Thorazine.

[Alie Ward]

Okay, I want to do like an hour long aside on Thorazine, but I'm going to make this snappy instead. I'm going to put it in bullet points. Invented by a French doctor in 1952 to help with pre surgery anesthesia, it was also used as an anti inflammatory. Now primarily used to manage hallucinations and mania and some symptoms of schizophrenia. But it's also been prescribed for everything from behavior problems, ADHD to barfing to hiccups. And there are some theories that cases of mild encephalitis cause schizophrenic like episodes, which is why Thorazine could have been helpful. But that's still being debated. Thorazine as a name brand doesn't exist anymore. Novartis took it off the market because of cardiac concerns. But it's a generic form called chlorpromazine. It's that still around. Now if you're like, why does Thorazine sound like a superhero made out of electrified muscle? Well, the lab that marketed Thorazine, named it after the Norse God of lightning and hammers, Thor, to reflect the reverberations that would roll across the medical world as a result of this revolutionary new drug. Their president said so, yes, Anyway, Thorazine, the thunderbolt of psychiatric drugs, sometimes striking

[Dr. Rachel Zoffness]

where it was not needed, like knocks them the f out. And this is a child. And he was on Thorazine for his pain, and it would knock him out for days at a time. So he wasn't going to school, he wasn't seeing friends, he wasn't functioning. It was wild. He had seen like more than 15 physicians. And I had been reading there's all these, like, protocol for treating chronic pain in both adults and children. And I had worked with a number of other patients, but I had never worked with a kid who had been in bed for four years. And I almost called the referring physician to say, I can't do it if you guys can't do it, I surely can't. I almost called them to send him back. But instead, the kid was so hopeless. Just to describe him to you, he showed up at my office. He had long unwashed hair. He was overweight because he hadn't moved his body in numbers of years. And he was rocking himself back and forth on my couch with the pain. I asked him if he had given up hope, and he said yes. So I made the decision to lie to him. Yes, I know it's a dubious decision. And I said, I can help you, but you have to do everything I say. And I knew, I mean, especially as a pain psychologist, nobody wants to go to a psychologist for pain because pain is sold to us as this purely physical or physiological problem. And if you go to a psychologist, the popular thought is, oh, they're saying it's all in my head. Or they're saying my pain isn't real or I'm faking it. Right? But that's not true. There's all these treatments that are evidence based for pain that are non pharmacological. So I said to him, I can treat you, but you have to do everything I say. He said, okay. And we went through this cognitive behavioral therapy protocol for pain management, which is now what I live and die by. And we started out doing very small things. At first it was like, just stand on your porch in the sunlight every day. And even that was hard for him. And we did, like a lot of work together. So then it was like walk to the corner mailbox and mail a letter. And, you know, and he was doing PT and OT at the same time. And then it was like, can we get a tutor to help you catch up in school? It was like small bits of activity, small goals, and really pacing him to desensitize his brain and body. Within three months, he was getting back to life. He was doing jogs around the block. He did get a tutor. He caught up with friends. He eventually went back to school and soccer.

[Alie Ward]

Wow. Yeah.

[Dr. Rachel Zoffness]

And the more he did, the more he realized he could do. The more his brain desensitized, the more his body was able to function and he was able to get back to life. And his pain remitted and his anxiety and depression did, too. And he actually graduated from high school a couple years ago, and he invited me to come.

[Alie Ward]

Oh, my God.

[Dr. Rachel Zoffness]

Yeah. So I went to his graduation, and this kid, he got on stage and he said, if you had told me four years ago I'd be graduating from high school, I never would have believed you. We all cried. And he went off to college and is like, swim captain. He still has pain episodes, but he knows exactly. And he's never going to be that kid who's in bed for four years ever again. No kid ever needs to be the kid that's in bed for four years ever. The way we mistreat pain just drives me nuts. So I think that really drives me. I think I went on a tangent, like, maybe a long one.

[Alie Ward]

That's beautiful. It's beautiful. So before we learn how pain psychology works, let's just be back it up and address the fundamental question, what is pain?

[Dr. Rachel Zoffness]

Right. What is pain?

[Alie Ward]

What is it and how much is it? Yeah. Mind, how much is it? Body, how much control do we have over it?

[Dr. Rachel Zoffness]

You're asking amazingly hard and awesome questions, and I'm going to answer them. So you can ask 40 different people, and you'll get 40 different answers, and I'm going to try and squish all the things together and make it as, like, digestible as possible. So if I don't do a good job, I'm going to rely on you to call me out. So pain is your body's warning system. By that I mean it exists to protect you and save your life. So I remember learning in this dorky neuroscience class that there are people who are born without the ability to feel pain.

[Alie Ward]

What?

[Dr. Rachel Zoffness]

Yes. And I remember thinking, that sounds delightful. And then our professor said, yeah, and they don't live very long.

[Alie Ward]

Oh, fuck.

[Dr. Rachel Zoffness]

Right? Because if you imagine you put your hand on a stove and you don't take it off, you go for A run and you break your leg and you just keep running. Because pain is actually your body's danger detection system. But like every system in the human body, the pain system can fail. So one of the biggest errors we often make as humans is believing that just because you have pain, it means necessarily that a body part is damaged or broken. And that's not always what pain means. You can actually have pain without damage in a particular body part is what we've learned. And that's what chronic pain is, believe it or not. So pain is also adaptive. Again, it's this thing that saves your life. It is also this word that I'm going to use that I've been told I shouldn't use because it's confusing, but I'm going to do it anyway. Let's have it. Biopsychosocial.

[Alie Ward]

Okay.

[Dr. Rachel Zoffness]

Yeah. What does that mean? Pain is biopsychosocial. So what that means is 100% of the time whether your pain is acute, which means short term. So any pain three months or less, or chronic pain, which is pain that's three months or longer or beyond expected healing time. Your pain lives in the middle of these three bubbles or domains that I'm gonna call. So one is biology, biological sources of pain, one is psychology or psychological sources of pain, and one is social or sociological. And I wanna say what that means. So if you imagine a Venn diagram, so there are these three bubbles that overlap, and in the middle where they overlap, that's where pain lives.

[Alie Ward]

Okay, pay attention. So Dr. Zoff is gonna break down the three sources of PA with biological

[Dr. Rachel Zoffness]

in the middle of these three things. So the biological components of pain are the things that you hear about all the time. So it's genetics and tissue damage and system dysfunction and like immune functioning and sleep and diet and exercise. And those are all very important when it comes to pain. We all know that. However, if you think about this Venn diagram, if you're only focusing on the bio component of pain, you're actually missing two thirds of the pain problem. Because we know that pain is this biopsychosocial phenomenon. And I promise I'll explain why. But then there's all these psychological components and all these social or sociological components. And the problem with pain management is that we focus just on the bio, which is pills and procedures. And a lot of people with chronic pain will confirm that it doesn't cure their pain because it's focusing just on one third of the problem.

[Alie Ward]

So, so here is the second source of pain and also where I freak

[Dr. Rachel Zoffness]

out in the psychological domain of pain, we've got, believe it or not, thoughts, because neuroscience tells us that how you think shockingly affects how you feel. So. Right. So if you imagine that you have this, like. If you imagine you have, like, this pain volume that lives in your brain, this pain dialogue, when you have anxious, stressed out, and depressed thoughts, pain volume actually gets turned up. So the things you think affect the way your body feels 100% of the time. Then in the psychological bubble, we also have things like trauma, because trauma 100% of the time also amplifies pain. There's these great studies called the ACEs studies, Adverse Childhood experiences. And they have shown that kids who have had adverse experiences, and by the way, adults too, who have trauma, it also amplifies this pain volume, this pain dial. So if you are someone who has had pain in childhood or in adulthood, chances are you're gonna be more susceptible to higher pain and or developing chronic pain. And in the psych bubble, also, there's memories. So there's a part of your brain called the hippocampus, and it stores all of your memories, and there's a dedicated portion for pain memories. So the first time you were held down and given an injection as a child, your hippocampus stores that why it's adaptive to remember the things that are painful, because those things might save your life. So memories also affect pain. There's also emotions. Emotions also affect pain. That seems not even intuitive. But research also shows that how you feel emotionally affects how your body feels, and we all know that, right? Like when you're depressed, your body feels heavy, your muscles feel sore. It's just, like, harder to get off the couch, right? Yeah, because emotions affect the body, too. And then there's coping behaviors also in the psych bubble. And coping behaviors just means what are you doing to manage your pain? When you have pain, what do you do? So some people, including me, as I mentioned, for a year, will stay inside on their couch, not exercising, not seeing friends, not moving. But what we know is that that's going to amplify pain also.

[Alie Ward]

Okay, so those first two bubbles were biological and psychological. What is the third bubble?

[Dr. Rachel Zoffness]

And then there's the social or the sociological bubble, and that's everything else. So socioeconomic status and access to care. I mean, if you're not talking about that, are you really talking about healthcare at all? Or pain or disease, race and ethnicity and racism in particular, what does that do to your stress system? And how does that affect your pain? There's also friends and family like, do you have a support network? Do you feel like you're connected socially or are you isolated? Being isolated or being socially supported affects how you feel all the time also. So all these things together as you imagine, like human beings are these complex animals with all these things going on, and they interact all of the time to affect your pain system. That was a long answer to your question.

[Alie Ward]

No, it was great. It was visual. Oh, and a fascinating fact. So the definition of pain has recently been changed to reflect those social and psychological components. So a 2020 piece in the Journal of Orthopedic and Sports Physical Therapy explains that the International association the Study of Pain has updated its definition of pain for the first time in four decades. And that the original definition of pain was an unpleasant sensory and emotional experience associated with actual or potential tissue damage, which was criticized for being too focused on actual tissue injury. And so the shiny new, updated 2020 definition of pain is an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage. So now pain does not need to be associated with actual injury. So Dr. Zoffness says the new definition leaves much to be desired, but it is an improvement upon past disco era definitions. But yes, right in line with her three sources of pain, and really different from this foggy, jumbled mess that I thought pain was, which is now painful to listen back to. And I never knew that there were three aspects of it. What I picture pain, I picture you have this nerve that looks like a thread and it has an injury on it, and it sends out electrical pulses that make your cells twitch. That is what I would think pain was. And that's not accurate at all.

[Dr. Rachel Zoffness]

Right, but that makes sense. A and B, they have done all this research that shows you do have receptors in your body that respond to things like touch and temperature and nociceptive input, which is potentially dangerous input. But what they've discovered is here's this really cool, really nerdy fun fact is that pain can't possibly live exclusively in the body. But we all think that. We all think, like, well, if I have back pain, that means definitely there's something wrong with my back, right? Or if I have knee pain, that means that the pain lives exclusively in my knee. But here's how we know that pain does not live exclusively in the body. There's a condition called phantom limb pain. And phantom limb pain is when someone literally loses a limb, like an arm or a leg, and they continue to have terrible, excruciating pain in the missing body part. So if you can have excruciating leg pain in a leg that isn't there. That has to mean that pain is produced somewhere else and that somewhere else is the brain. So you definitely have these receptors in your body that are communicating messages up to your brain. And your brain is always sending messages back down to your body. It's definitely like a two way street. They're always working together. But the part of your body ultimately that constructs pain has to be your brain.

[Alie Ward]

And how do you know of those three bubbles, what is the biggest contributing factor? Like if you have a slipped disc in your back and that definitely hurts, versus if the X rays show nothing but there is chronic pain, how do you know how to start to address it?

[Dr. Rachel Zoffness]

Here's the answer. So the answer is all three things are always contributing all of the time. And yes, in any given moment, something in any one of those bubbles might be like activated or up, but they're always, all three are always acting all of the time. So there's always this like recipe for pain, whether it's high or low. And the recipe always, 100% of the time includes all three bubbles. But you're right, right? So with acute pain, which is short term pain, it is usually a message that there's something going on with your body that you need to check out, right? So like for example, let's say someone has knee surgery, you bet your ass your body's gonna be giving you all of these messages. Something's wrong, like some. And yes, someone has just sliced into your tissue, like, yeah. And you're healing. But so with acute pain, yes, you wanna check that out and find out what's going on with your body. It's a little bit different with chronic pain and I'm gonna tell you why. But to go back to your original question, if we don't address all three things, we're not ever addressing pain. So if you imagine there's this like common analogy, if you stub your toe on a day you get fired, you've just lost your income and you don't know if you're gonna be able to afford your rent, when you stub your toe, you're gonna be cursing and screaming and it's gonna feel awful. If you stub your toe when you're out with your friends eating ice cream, you're out in the sun, you're having a lot of fun. It feels qualitatively different to you. Your brain interprets the message differently depending on circumstance, environment, how you're feeling emotionally, where you are, who you're with what's happening, how you interpret the sensation. So the answer is, even with acute pain, all the time, all those things are working in concert. So if you go to a children's hospital in the ward, you'll see there's murals on the wall and stuffies on the chairs. And there's a reason for that, because when you help people feel safe and calm, your pain system is gonna feel better too. It's gonna be less on alert. And that's true with adults also. So whether acute pain or chronic pain all the time, all the things are always working together.

[Alie Ward]

And what about the biological methods that we have right now? Like how does aspirin work, how does aleve work? How does ibuprofen work? How do opiates work? What are they blocking? Because sometimes that absolutely blows my mind that I can take something and a migraine will go away.

[Dr. Rachel Zoffness]

100%. Absolutely. Yes, that is totally true. And all the medications work in different ways, but they target receptors in your brain to block what I'm gonna call pain messages.

[Alie Ward]

So yes, chemically it's pretty complex, but just think of pain relievers fitting and locking into places and thus just ruining the vibe of the pain messages. Real cock blockers.

[Dr. Rachel Zoffness]

But what's really interesting to me about opioids, by the way, and all these medications, but opioids in particular, cause there's so much talk about opioids and pain, is that opioids work on an endogenous receptor in your brain. By that I mean you already produce a chemical in your brain that opioids imitate, and they're called endorphins. So if you hear of like a runner's high after you go for a run, your brain produces this opioid substance called endorphins. And so opioids bind to that receptor. So it's true of all medications. Whenever you take a medication, it's binding to a receptor in your brain for a chemical your brain already makes.

[Alie Ward]

And side note, we're going to do a whole episode in the future on mechanology, which is the study of opium and opiates, including the epidemic of opioid addiction. But yes, medicines have pluses and minuses depending on their use.

[Dr. Rachel Zoffness]

And I also need to be very careful and clear with. So I am in no way anti medication. Like I'm like a person who's like, thank God that opioids and other analgesics exist for post surgical pain and things like migraine and all the other horrible things that happen to human beings, like super helpful, super wonderful and very important. And simultaneously, because pain is so mistreated in our country, and because there's such poor pain education in medical school, in psychology programs, in nursing programs across the board, we completely and utterly mistreat pain. And people are told that medications are the only answer. So people living with chronic pain oftentimes feel really helpless and hopeless because either their medication is being taken away from them or there's like a lot of controversy around it or they feel like they don't have other options or alternatives. So thank God for medication. And it is not the only answer. And controversially, and like I'm gonna get in trouble for saying this, but I'm gonna say it anyway. The problem with opioids for pain. And by the way, this is not like I didn't make this up. This is just what research shows over time. Opioids sensitize the brain to pain over time. Yeah, there's a whole. There' sit's a sensitization syndrome. It's a well known established fact.

[Alie Ward]

Okay, side note, I went to fact check this and look it up and it's called opioid Induced hyperalgesia. And yes, it is well, well established in countless papers with titles like Elevated Pain Sensitivity in Chronic Pain Patients At Risk for Opioid Misuse, and Sensitized Brain Response to Acute Pain in Patients Using Prescription Opiates for Chronic Pain. So yes, Google opioid induced hyperalgesia. It's like a closet just stuffed with items. But instead of umbrellas and bowling balls falling onto your face, you're just gonna be covered in studies about pain and opioids. So Dr. Zoff explains.

[Dr. Rachel Zoffness]

So actually what happens over time is that your brain gets more and more tuned in to the sensory messages coming from your body. So if you ever try and go off, of course you're gonna feel awful and terrible. And again, I am not anti opioid, I'm not anti medication. But it seems important for people to know that long term their brain is gonna get extra sensitive.

[Alie Ward]

Now what about someone who is experiencing pain? Let's say it's chronic, let's say it's ongoing. Where do you even start that CBT or something that is non pharmacological? Like do you just do like a pain check in? Do you just sit and try and figure out like what hurts where and why?

[Dr. Rachel Zoffness]

Can I answer your question in a sort of backwards way?

[Alie Ward]

Yes.

[Dr. Rachel Zoffness]

So chronic pain is its own animal, it's considered its own disease process. So here's what happens with chronic pain. So to answer Your question? Thing that I do is I explain how pain works. And I always ask people who come to my office who have been in pain for, like, 10 years, hey, has anyone ever explained how pain works to you?

[Alie Ward]

And they're like, no.

[Dr. Rachel Zoffness]

A hundred percent of people say no, which is so wild to me. Like, you've had pain for 10 years. People will explain how the liver works, but they've never explained how pain works. That's crazy pants. So we've established that pain is constructed by the brain, of course, in conjunction with the body. We've established that acute pain and chronic pain are different. They work differently. There's receptors in the body, but the brain is always working, working with all of the information to decide whether or not to make pain and how much,

[Alie Ward]

just to differentiate here. Acute pain is typically sudden in onset, and it serves a purpose, like telling you this is hot, or, hey, something is gnawing on you. And acute pain usually responds to treatment. Now, chronic pain outlasts the injury and is long term lasting weeks to even years. And the CDC estimated in 2018 that 50 million Americans, that's 1 in 5, has some form of chronic pain. And it costs up to $635 billion per year to treat, billions of that coming out of pocket by people experiencing it, not to mention lost wages and quality of life. So people with chronic pain are already suffering, and then on top of that, they may not even be told how or why things hurt. So Rachel, of course, is enthusiastic to lay it out because she is the

[Dr. Rachel Zoffness]

best with chronic pain. Here's what happens. So I'm gonna ask you a question.

[Alie Ward]

Okay.

[Dr. Rachel Zoffness]

Have you ever practiced anything, like, any skill that you were bad at, and you practiced it and you got good at it?

[Alie Ward]

Absolutely.

[Dr. Rachel Zoffness]

Give me a thing.

[Alie Ward]

Ukulele.

[Dr. Rachel Zoffness]

Oh, that's the best one. Yes. Great, great. Have you noticed with the ukulele, eventually your fingers sort of know what to do?

[Alie Ward]

Yeah, yeah, absolutely. And I can go faster on a song I never have played in front of anyone. It's just something I do because it's fun to do alone, you know, if

[Dr. Rachel Zoffness]

I had known that, I would have demanded that you brought your ukulele.

[Alie Ward]

No, you can't do it in front of him. But yeah, and I can. And I can think about the song before positioning each finger.

[Dr. Rachel Zoffness]

Yeah.

[Alie Ward]

So totally.

[Dr. Rachel Zoffness]

Right. So I'm going to say it back to you a little differently in, like, the neuroscience nerd way.

[Alie Ward]

Okay.

[Dr. Rachel Zoffness]

The pathways in your brain are like the muscles in your body. The more you use them, the bigger and stronger they Get. So if you said to me, zofnus, I want huge biceps, I would say, allie, of course you do. Go to the gym and lift weights a lot. Or, like, actually be isolated at home, whatever. Lift weights a lot. And over time, your biceps will get big and strong. It's the same with the pathways in your brain. The more you use them for any particular thing, the bigger and stronger they get. So the more you practice ukulele, the bigger and stronger the ukulele pathway in your brain gets. Like, you can hear the notes, your fingers know what to do on the strings, you know how to position the instrument. And that's with practice, over time. Guess what happens when you inadvertently accidentally practice pain over and over for weeks and months and years?

[Alie Ward]

Oish, same thing.

[Dr. Rachel Zoffness]

The pain pathway in your brain gets really big and strong. And when that happens, we say that your brain has become sensitive to pain. What does that mean? That took me a long time to figure out. How do you explain that to someone? What does that mean, that your brain is sensitive to pain? What it means is that small bits of sensory input from your body are interpreted by a sensitive brain as very big. So, like, dogs are sensitive to smell, right? Or sense. So if a dog came in here right now and sniffed around, they would pick up on these scents that you and I can't even detect because their brain is sensitive to smell. So with pain, when your brain is sensitive to pain, it means that you might have little bits of sensory input coming from your body that are not dangerous, that are not dangerous, but your brain is gonna amplify it and tell you that it's dangerous. And that's what pain is. It's this big danger response, this big danger warning message that actually is inaccurate, and that's chronic pain. So the system. One of the systems underlying chronic pain is this process. It's called central sensitization. And it doesn't underlie all pain, but it explains a lot of chronic pain. And to me, it's so fascinating to be able to say to someone, hey, the chances are really high that your brain is hypersensitive and it's overreacting and it's not your fault, but it's giving you these danger messages when in fact, your body might not be in danger. So, for example, with fibromyalgia, which is a chronic pain condition, you can go for a picnic with your friends and be sitting outside and be in terrible pain. But is having a picnic with your friends dangerous? And the answer is no. But your brain is producing these danger messages, and Telling you you should go home and isolate and be alone and not move and not see your friends. And that is a big fat lie. And if you listen to your brain and you do those things and you go and isolate and you lay on your couch for 40 years, you are not gonna get better. So the treatment for chronic pain is the total opposite of what you think it is. Your body and your brain are telling you, isolate, stay home, don't move. And the treatment for chronic pain is like. My metaphor is like, if you've ever been in a dark room and someone opens the blinds a little bit and you're like, ah, close the blinds, I can't see. Because your brain is sensitive to light when you've been in a dark room. But if you sit there for two minutes, your brain desensitizes to the light, and then you're fine, right? And if they open the blinds a little more, you're like, shit, close the blinds.

[Alie Ward]

I can't see.

[Dr. Rachel Zoffness]

And then eventually, two minutes later, your brain desensitizes. You're fine. Treatment for chronic pain, and that's what cognitive behavioral therapy is, by the way, is helping someone's brain and body desensitize to little bits of stimulation a little bit at a time, until, like, someone who's in a dark room, suddenly you're in a room full of light, gradually, little bits at a time, and your brain and body are, okay, so that's the treatment. But you're not going to buy into the treatment unless you understand the science. So that's why it's so important to me to always lay that foundation.

[Alie Ward]

And is the amygdala at all involved in this? Like, is anxiety and fear? Is that a big part of pain perception?

[Dr. Rachel Zoffness]

Yeah.

[Alie Ward]

Ah. Had a feeling. Old Amy up there fucking shit up 100%.

[Dr. Rachel Zoffness]

Yes. Yeah. Okay, so crash course in Pain neuroscience. Pain Neuroscience 101. Here's how it goes. Ready? Okay.

[Alie Ward]

I'm so ready. Let's hear what parts of your head are being a literal pain in your ass.

[Dr. Rachel Zoffness]

So there's lots of parts of your brain that contribute to pain. With some things, it's like, oh, there's just one part of your brain. But with pain, it's a diffuse neurological process. And what that means is, is there's lots of parts of your brain that contribute to this experience we call pain. So I'm gonna tell you a couple of parts of the brain, okay? One is your cerebral cortex, okay? Your cerebral cortex is the part of your brain responsible for thoughts. Thoughts contribute to pain all the time. The second part of your brain is your prefrontal cortex, and that's the part of your brain responsible for executive functioning and attention. What you're focusing on, what you're thinking about. And the third part of the brain is your amygdala. Limbic system. Yes, your limbic system. And your amygdala is a major part of your brain's limbic system. And your limbic system, by the by, is your brain's emotion center. And here's what this means. That means that 100%, and I'm not exaggerating, 100% of the sensory signals that come from your body filter through your emotion center before they become this experience we call pain. So people always ask me, do you treat physical pain or emotional pain? Like, oh, you're a pain psychologist, that's so weird. And do you treat physical pain or emotional pain? And the answer is always, necessarily, yes. Yes. Because pain is always physical and emotional. It's filtering through your limbic system, it's filtering through your emotion center before it becomes this complex experience we call pain. So, yes. So now I want you to imagine we sort of touched on this earlier, that you have what I'm going to call a pain dial, like the volume knob on your car stereo and you can turn it up and down. And it lives in your central nervous system, your brain and your spinal cord, which work together to control all the. Including pain.

[Alie Ward]

Yeah.

[Dr. Rachel Zoffness]

So here's how this works. Lots of things can change pain volume. Whether it's acute pain or chronic pain, whether you've had it for five seconds or 10 years, lots of factors change pain volume to turn it up and down. So three things I want to tell you about. One is stress and anxiety always changes pain volume.

[Alie Ward]

Oh, no.

[Dr. Rachel Zoffness]

I know, right? During a pandemic. During a pandemic.

[Alie Ward]

Oh, no.

[Dr. Rachel Zoffness]

Chronic pain during the pandemic went through the roof. Opioid related overdoses went up 40%. Calls to suicide hotlines went up 8,000%. Oh, my God, dude, people are suffering. People are really so people in pain because of all this neuroscience we're talking about, it makes sense, right? So stress and anxiety. Thing two is mood and emotions always change pain volume. And thing three is attention or what you're focusing on. So I'm going to tell you specifically how this works.

[Alie Ward]

So, so again, that was stress, emotions and attention.

[Dr. Rachel Zoffness]

When stress and anxiety are high and your body and your muscles are tense and tight, which is what happens when you're stressed and anxious and your thoughts are worried, your brain sends a message to this pain dial, turning up pain volume. So whatever pain you had before, when you're stressed or anxious, like you just lost your job or it's a pandemic, or like whatever you're stressed out because you're fighting with your partner or whatever, your brain is going to amplify pain volume. Pain is going to feel worse when stress and anxiety are high. And anyone with any chronic pain condition will tell you that stress and anxiety can be a trigger or an amplifier of pain. Thing two is mood. So again, negative emotions. So when your mood is low and you're miserable and depressed, which ironically happens when you have pain, or emotions are negative in general, or you're angry or you're very frustrated, your limbic system, including your amygdala, of course, which is. Which is implicated in all the negative, will amplify pain volume. So pain feels worse when emotions are negative. And thing three is attention. Again, what you're focusing on. So when you are sitting in bed or laying on your couch and you're focusing on your body and you're thinking about your pain, that body part that's hurting, your prefrontal cortex sends a message to that pain dial, raising pain volume. So pain feels worse when you're thinking about it and when you're focusing on the body part that hurts. But the reason this is critically important for those of us who have pain, which is 100% of us, is that the opposite is also true. The opposite is also true. And if you think about the implications for pain management, that's pretty wild. So let's talk about the opposite. When stress and anxiety are low, your body and your muscles are relaxed and your thoughts are calm, your brain sends a message to that pain dial, lowering pain volume. So pain feels less bad when you are relaxed and calm. Thing two is mood emotions. So when your emotions are positive, you're feeling happy and joyful and grateful and you're doing fun things with friends, your limbic system lowers pain volume. Pain feels less bad when emotions are positive. And thing three is attention. So when you are distracted, when you're so absorbed in some activity, you briefly forget about your pain. We've all had that experience. That is not magic. That is your brain's pain dial. So your brain, your prefrontal cortex will lower this pain dial. When you are absorbed in things and you're not thinking about your body and you're not thinking about pain. So that's why when you go to give a child a vaccine, which everyone should do, and get an injection, you give them a screen, and they can watch their favorite show, and they're distracted, and it hurts less. So all these things together in my mind help us understand that pain, again, is. Is this biopsychosocial thing that's regulated by mood and thoughts and what you're focusing on and where you are and who you're with and your context. And all those things are going to matter to your brain when it makes this pain decision, whether or not to make pain and how much.

[Alie Ward]

And so what are some of the first steps? If someone doesn't have the privilege of being your specific patient, for example, or maybe their psychologists or their medical doctors don't have this much information in their brains about it? Where do you start with people? Do you start with just, like, start meditating, go on the porch? Where do you even begin?

[Dr. Rachel Zoffness]

So I do this treatment called cognitive behavioral therapy, and there's a lot of misunderstanding and misinformation about what that is and how it applies to pain. So what it is, is it's a treatment that was originally developed for anxiety and depression that does have evidence of effectiveness. And it also is a treatment, by the way, for sleep. Sleep and family dysfunction and all these other things, by the way, that also contribute to pain, which is so fascinating to me because all the things are interconnected. So it makes sense to me that this thing might be useful for pain. And it teaches us that how you think affects how you feel, emotionally, affects how you feel, physically affects how you behave or act. So round and round in a circle. What you think affects how you feel, affects. Affects how your body feels, affects how you act. And. And I can give you an example of that. So let's say someone invites you to a party, okay? They're like, alie ward, it's been like a year and a half. Pandemic. Come to my house. We're gonna have a party in my backyard. It's gonna be really fun. And you have this thought in your head. You think to yourself, I am a loser, and nobody likes me. And if I go to the party, no one will talk to me. I'll just be standing by myself.

[Alie Ward]

At this point, I was feeling depressed and ashamed.

[Dr. Rachel Zoffness]

That thought is going to affect your emotions. How might you feel if you thought that thought?

[Alie Ward]

Oh, depressed and ashamed.

[Dr. Rachel Zoffness]

100%, yes. Right. So you're feeling depressed and miserable and ashamed. So how does depression affect your body?

[Alie Ward]

I think I would have a harder time getting up and getting ready for it.

[Dr. Rachel Zoffness]

That's right.

[Alie Ward]

I think I would sink into whatever soft fabric I am sitting on at the moment.

[Dr. Rachel Zoffness]

100%. Yes. So we know that negative emotions impact the body. Right. And I like to say that negative emotions don't just live in your head. They also come out in your body. And if you've ever been stressed out or nervous and your palms get sweaty and your mouth goes dry and your heart races, these weak arms are heavy.

[Alie Ward]

There's vomit on a sweater already.

[Dr. Rachel Zoffness]

Mom's spaghetti. Of course emotions come out in your body. Or if you've ever been depressed, you know that you feel heavy and unmotivated.

[Alie Ward]

So.

[Dr. Rachel Zoffness]

Right. So that thought, I'm a loser, nobody likes me, I'm gonna have a terrible time is gonna trigger negative emotions, and that's gonna affect your body. You're gonna feel unmotivated and heavy. So what do you do as a result of those thoughts and feelings? You already said it perfectly.

[Alie Ward]

You sink into a couch. And then I send a text about being on deadline, which is a lie.

[Dr. Rachel Zoffness]

Right? Right. And you, like, put on your fuzzy pajamas, and you get a tub of ice cream, and you binge watch Netflix Total. Exactly. But the cycle spins around. So now you're missing out on the party on your couch, and you're in your pajamas eating a tub of ice cream. And what are you thinking to yourself, now? I'm a rock star? Or are you thinking, I. I am

[Alie Ward]

the lizard that I thought that I was?

[Dr. Rachel Zoffness]

100%. Yes. And that's what we call the cognitive behavioral therapy cycle of how thoughts affect the brain, affect the body. Right. But now let me give you the opposite. Someone says, alie Ward, come to my house. We're having a great party. You can wear whatever dress you want, put on your nicest shoes, and you think to yourself, I am a rockstar. People love me. I'm the life of the party. I'm gonna break dance. I'm gonna pull out my breakdancing moves, and I'm gonna, like, bake brownies and, like, bring them. Everyone's just gonna think, how does that thought make you feel?

[Alie Ward]

Oh, I. Lighter and excited and a little nervous.

[Dr. Rachel Zoffness]

Great. Love that constellation of emotions. Right. Excite. Totally excited, A little nervous. So how does that affect the body? Usually when you're excited, you have a lot of energy. You know, you feel, like, motivated. And then what's your behavior? What do you do?

[Alie Ward]

Definitely put on lipstick, do some mascara, dig out the liquid liner, bake some brownies, eat some of the batter if I want to.

[Dr. Rachel Zoffness]

Totally.

[Alie Ward]

Yeah. And then. And maybe even leave the house on time.

[Dr. Rachel Zoffness]

That's right. So you go to the party. Yeah. That's right. You show up at the party and you're dressed and you bring some brownies, chances are pretty high. Some person is going to be talking to you. And if you're really feeling like, if you're thinking, I'm a rock star, I'm going to have fun, chances are high. You probably. You probably will. You'll attract someone to come talk to you. Right?

[Alie Ward]

Right.

[Dr. Rachel Zoffness]

So. So the things you think affect, the things you feel affect how you behave. Always. That's always true. And the shit of it is when you're anxious and depressed, you get stuck in these thought cycles that contribute to the perpetuation of the cycle. And you can see how that would easily happen. Yeah. And it happens with pain also, when you have pain. A lot of the thoughts that I hear are, I'm broken. I'll never get better. Nothing has helped me, so nothing is going to help me. Why bother? Right. And that makes you feel anxious and depressed. And what we already know from pain neuroscience is that that's gonna amplify pain, so your body's gonna feel worse, and how are you gonna act as a result? You're gonna stay inside on your couch with a tub of ice cream in your Snuggie or whatever, and it's gonna be very hard for you to break that pain cycle. So what we do in cognitive behavioral therapy, or cbt, is every individual is unique who comes into my office, and my job is to educate them about pain in their body and then to figure out what's that person's unique cycle. Because you bet they're thinking their own unique thoughts and feeling their own unique feelings, and they are down whatever coping rabbit hole they're down, and everyone is doing the best they can to manage their pain. Right. This is like not a critique. Everyone is doing the best they can. And if you really believe that staying on your couch for five weeks is the answer or five years, that's what you're gonna do. Right. So it's like, what is your cycle? How do I help you break it? And you can break it by going after the thoughts, and you can break going after the emotions, and you can break it by going after the behaviors. So what I happen to like to do with my patients the best is change behaviors first.

[Alie Ward]

Oh, so you go backwards on the wheel.

[Dr. Rachel Zoffness]

So I should have said this. The wheel can go in any direction. Because if you think about it, if you just start with the behaviors, you're laying in bed for five years.

[Alie Ward]

Yeah.

[Dr. Rachel Zoffness]

Right. What are you thinking and how are you Feeling you can start. That's what I like about the wheel. Everything affects everything. It's multi directional. It's always spinning in every direction. And what I like about behaviors, like, thoughts are really complicated. It's really hard to challenge your thoughts. But with behaviors, it's like, okay, what's one thing I can do today that will get me off the couch? Like, I want to make fudge. Can I send my friend out to help me buy ingredients and, like, walk to my kitchen? You know? So what are small little things I can do to break the cycle? And I find that that's often a good place to start because once you change a behavior, you can get a little motivation or forward motion going. So, like, full circle. To the kiddo who had been in bed for four years, the first thing had him do was stand on his porch and get a little sunlight. And like, eventually within a couple weeks, he, like went and got a haircut, which sounds like a small thing.

[Alie Ward]

Yeah.

[Dr. Rachel Zoffness]

But when you have long, long unwashed hair for four years and you look in the mirror all the time, that's reinforcing the romp. Like, you can't feel so, so great. When he wanted went and got a haircut, dude, that kid was a different kid. It was a small thing, but it really pushed us forward. I know that sounds really weird when you're talking about pain.

[Alie Ward]

Yeah.

[Dr. Rachel Zoffness]

But it, like, really changes the cycle. Cycle.

[Alie Ward]

And so do you ever recommend having like, an accountability buddy or a journal or what's a tool that you can use to kind of keep your mind in the CBT other than a therapist in a workbook?

[Dr. Rachel Zoffness]

I love accountability buddies. Definitely. So science shows that social support Absolutely. Always changes the brain and body. So if you have someone you can do the things with a hundred percent. Yes, I do also like journaling. I think that's very helpful too, because when you write stuff down, you're your own accountability partner sometimes. And when you write stuff down, you can track your progress and you can, like, see your change. You're like, oh, I did that thing. And then I felt more motivated to do that thing. I do also think that workbooks are useful for people and they're sometimes really dorky, but it's like a guided path toward accomplishing a goal. And it's very hard to know what to do. Like, here I am spouting like, I'm making it sound easy. It's so hard to live with pain every day. It's so discouraging. It's so, so hard.

[Alie Ward]

So Dr. Zoffness says working with anyone on this can be helpful, whether it's a friend or a partner, an accountability buddy. Or you can get a physical therapist or an occupational therapist, any therapist who could maybe go with you through a workbook. Or you could try to find a pain psychologist. Which is what exactly?

[Dr. Rachel Zoffness]

So what is pain psychology again? I wanted to live at this intersection of neuroscience and medicine and psychology and helping people in science writing and pain psychology is kind of that. So pain psychology is how do you put together this complicated thing we call pain and deliver it to the unique person sitting in front of you in a package that they can digest and understand that isn't stigmatizing? Because that's the worst part for me about being a pain psychologist is everyone who comes to see me believes that their physician has given them this message. It's all in your head, or you're faking it, or it's just psychological. Your pain is just psychological. And that's never true of pain. We know pain is always biopsychosocial. It's always, like you said, migraines. It's always change in blood pressure, changes in blood flow, and it's changes in how your brain is working. But it's also changes in stress and anxiety and what's happening in your environment around you and your diet. And it's all the things working together. Right? So a pain psychologist looks at this complicated picture and tries to figure out, what do we need to do to help your pain? And what does your pain recipe look like? And I want to tell you what a pain recipe is.

[Alie Ward]

Since she explained this to me, I have thought about it every single day since.

[Dr. Rachel Zoffness]

So a pain recipe in my mind is like, I don't know why I'm talking so much about brownies. I must, like, just really want them. But if you're someone who, like, bakes brownies, you know, there's a recipe for awesome brownies. And it's like you have to mix these particular ingredients together and particular amounts of them, and you have to put it in the oven for a particular amount of time. And if you don't, the brownies are not gonna be cooked, or they're gonna be burned, or they're gonna taste really disgusting. Cause you forgot the chocolate, you know, so. And it's the same with pain. There's always a recipe for high pain, like a really bad migraine day. And there's always a recipe for low pain, like a day I'm feeling awesome. And if you ask people, they will often know what their high pain recipe is.

[Alie Ward]

Oh, absolutely. With migraines I know exactly like not enough sleep, not enough water, stressful day. And I know that it's gotta have those three, usually those three factors and it's like doh, did it baby, you got it.

[Dr. Rachel Zoffness]

Yeah, that's exactly right. And so the trick for me is if we know what the high pain recipe is, how do we puzzle out what the low pain recipe is? So you're right, like sleep on the high pain recipe. It's often like this combination of sleep and I'm not eating well and I'm like fighting with partner or there's a lot of stress at work or you know, whatever. There's like a lot of other stressors and things going on in my life too. And I'm not exercising and I'm not taking care of my body. And so it's like all these biological, psychological and sociological factors all the time interacting. So when we think about a pain recipe, I'm looking at all three of those bubbles. As a pain psychologist, I'm like, okay, what do I pull from this bubble and this bubble and this bubble to make this person's high pain recipe? And then what do I need to make a low pain recipe? And the thing about a low pain recipe is it's just the effing opposite. So it's like getting a good night's sleep and taking care of my body and managing my stress and anxiety and staying hydrated and putting limits on toxic relationships and saying no. I have a problem saying no. People come to me and they're suffering and dude, it is so hard for me to turn people away and say no or do things where I'm spreading this to me feels so critical, this information about pain. And I have opportunities to do that. And I want everyone to know and to have power over their bodies. So anyway, there's all these lines we have to draw in the sand if we wanna have a low pain recipe. Like how do we take care of our bodies in any given moment so that we're gonna feel okay? So that is my like down and dirty. Like what does a pain psychologist do?

[Alie Ward]

Oh, I love that. I love that. Thinking of it as a pain recipe.

[Dr. Rachel Zoffness]

A hundred percent. Yes.

[Alie Ward]

I have so many questions from listeners. Can I fire them at you?

[Dr. Rachel Zoffness]

Oh, you do?

[Alie Ward]

Yeah.

[Dr. Rachel Zoffness]

Oh wow. Cause pain is like, that's the thing that, that's like exactly why I wanna do stuff like this. It's like pain is this ubiquitous human experience that no one has been told anything about. It makes, makes me mad.

[Alie Ward]

I know, but real Quick, before we take your questions, we're going to give some money away. But before we do that, 2026, me again. And finally, finally, Dr. Zoffness has a new book for you. I have a copy. It's wonderful. I chatted with her on the phone this morning and I asked her to send In a little 2026 updated message just for you. So this just in.

[Dr. Rachel Zoffness]

Hey, Ally and Ologies famous. Here's what I've been up to since dolerology, which was somehow five years ago. I do not know how that's possible. I'm still teaching at Stanford and ucsf. I'm still doing a ton of science communication to help spread the word about pain, science and treatment. I also have wanted to be a science writer my whole life. I wanted to be Oliver Sacks when I grew up. I also think the true science of how painful works is so fundamentally important because we literally will never, never know how to treat it unless we all understand it. So I have spent the last five years scrambling to get a literary agent, which is quite challenging, and writing a book. Tell me where it hurts. I want to transparently say that writing this book was one of the hardest things I've ever done. I. I expected it to be a romantic undertaking where I was sitting at a writing desk with a mug of tea and a crackling fire while rain poured down around me. But instead I found myself in isolation for three years with my own thoughts and self criticisms. And man, was that brutal. But I am really proud of the book. I think it encompasses 65 years of neuroscience and most importantly, recent discoveries about trauma and pain. And also what surprised me when I was researching and writing this book was how disproportionately certain populations live with pain particularly. And this will surprise no one, women, racial and ethnic minorities, gender non conforming, and the LGBTQ community. And I dedicated an entire chapter to the science of why that's happening. And I had to fight to keep that in the book. And I'm really proud of how it turned out. So it's on Amazon and bookshop.org and any place you get your books. And I am so grateful to have the Ologies community, my community of passionate science nerds. And I'm hoping that this information is of use to you and to the people you love, love, and that it helps you understand better what's happening to your body, what's happening to your brain, this overlap between physical and emotional pain. And I hope sincerely that it helps you on your journey to healing, because that's really why we're all here. Thank you most of all to dad Ward and of course to Gremmy again.

[Alie Ward]

Her new book, it was just published in spring of 2026, is tell me Where It Hurts. And also great news. Other updates. Jarrett's torn ACL surgery was a glowing success. It took a while to heal and we even made an episode about it called Genicular Traumatology. All about your shitty knees in case you have bad ones. We're going to link in the show notes. So your podmother Jarrett, he. This is going to make me cry. Even healed enough to continue doing jiu jitsu. And he got his black belt after 17 years since we recorded this. It hasn't been 17 years since we recorded this. 17 years since. Since he's been judged. Anyway, Grammy is now 13. She has Milky eyes but a lust for cheese. And she jumps around like a lamb in the grass. And she's stinky as ever. Okay, back to money. Each week we donate to a charity of the Ologist's Choice. And Rachel says that she sometimes sees kids with medical conditions who come out as gay or trans over the course of their treatment. And she says she's always so honored to be part of their journeys and that more safe spaces need to be created in medicine for kids to talk about gender and sexuality. Especially because suicide rates are so high in the LGBTQ youth. So she would like to please donate to the Trevor Project to support these brave, strong, amazing kids. She says. And the Trevor Project is the world's largest suicide prevention and crisis intervention organization for LGBTQ youth. So money in their direction. Thank you sponsors. This podcast is brought to you by Squarespace. So is my entire life. I've used Squarespace ever since I started this PODC podcast. So whether you're just starting out or you are scaling your business, Squarespace is an all in one website platform. It's designed to help your business stand out and succeed. They give you everything you need to offer your services to get paid all in one place. Whether you're doing things like consultations or events, you can show the world what you do with this great customizable website. It's designed to help grow your business. You can get paid on on time. I love that they have on brand invoices, they have online payment. All of the things that you are overwhelmed to do Squarespace can handle. You can also streamline your workflow. They have built in appointment scheduling and email marketing tools which are huge right now. Again, I love Squarespace. Whether you are starting from the ground up, and you just need a simple website. Or if you're a business and you want better, more streamlined portals. Squarespace. They know I love them. You know I love them. So head to squarespace.com ologies for a free trial and when you're ready to launch, use the offer code ologies to save 10% off your first purchase of a website or a domain. Go do it. Sometimes to thrive, from your head to your heels, you got to start with your mouth. I take Nature's Bounty every day. You can support your daily routine with vitamins, supplements, a few things I have in my cabinet that I take every day. They have an advanced hair, skin and nails gummy that I love. It's strawberry flavored. If you are experiencing hot flashes, night sweats, perhaps some menopause relief tablets. Got a lot of my friends onto those. They're formulated to help provide multi symptom support and relief. Also, I take magnesium glycinate capsules every day I have for years. They help support heart, bone, nerve and muscle health. I even travel with these. Put some on your desk at work just in case you forget. So yeah, in particular they can prime my magnesium glycinate out of my cold, nervous hands. Couldn't live without it. Nature's Bounty. It's in your nature. Learn more at Nature's Bounty. Calm. These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease. Let me tell you what your mom doesn't need. She doesn't need a bath bomb. Here's what I get for pretty much everyone I love. An aura frame. It's the perfect Mother's Day gift to catch capture the chaos that you've put her through and the memories that came with it. You can upload pictures to it. You can add other people to upload pictures to it. And then she has this frame and it's all of these memories of the life you've built together. You can even preload the photos before the frame ships so it arrives already filled with your favorite memories and a custom message that can be added to create like a moment during the unboxing. It's ready to enjoy. Unique to her. It's so thoughtful and it's a gift that feels one of a kind that she will literally use every day. You know what Jared did today? He pointed at the aura frame and he said oh, remember that? And I looked over. It was our wedding day. The next picture, our dog in a hat. I love it. Named number one by Wirecutter. You can save on the gifts mom loves by visiting auraframes.com for a limited time time. Listeners can get 25 off their best selling Carver matte frame with the code Ologies that's a U R A frames.com promo code Ologies Support the show by mentioning us at checkout. Terms and conditions apply.

[Dr. Rachel Zoffness]

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[Alie Ward]

out plus our five year price guarantee

[Dr. Rachel Zoffness]

and and now T Mobile is available in US Cellular stores. Best Mobile Network Based on analysis by Oogle of speed test intelligence data 2H2025 bigger network the combination of T Mobile's and US cellular network footprints will enhance the T Mobile network's coverage price guarantee on talk, text and data exclusions like taxes and fees apply. See t mobile.com for details. Substance use disorder and addiction is so isolating. And so as a black black woman in recovery, hope must be loud. It grows louder when you ask for help and you're vulnerable. It is the thread that lets you know that no matter what happens, you will be okay. When we learn the power of hope recovery is possible, find out [e-mail] brought to you by the National Council for Mental well Being, Shatterproof and the AD

[Alie Ward]

Council okay, let's start by answering your burning curiosities about fiery redheads from patrons. Mark Hewlett, Jason Kraus, Andrea Marsh, Carly Lowe first time question askers Melissa Avignon Redford, Aaron Sorenson, Alyssa Benson Self identified smokin hot redhead Nina Giaccabe and okay Nadine says I've heard that redheads have a different pain tolerance than the general population. Is this true? Nadine is a first time question asking ask her many other gingers ask this as well. And as someone who's a fake ginger I feel like I have like dentists be like I know redheads and I'm like who are we fooling? You see my gray roots? So I am not a real redhead. But yeah what what's going on genetically with that?

[Dr. Rachel Zoffness]

Here's the honest answer. And by the way, you know a good healthcare provider when they give you this answer the honest answer is I don't know what the research says. However I will tell you that this if you are someone who is sensitive and I have absolutely no idea if there's any actual data on whether redheads are more sensitive than any other person but if you are someone who is sensitive and by sensitive I mean you were a sensitive child smell and Touch and your senses are heightened or you're emotionally sensitive and you pick up on things. That means by the. By friends and listeners, your brain is sensitive. When your brain is sensitive, guess what? It's more sensitive. Sensitive to sensory input from your body also. Why? Because a sensitive brain is more likely to amplify warning and danger messages from the body and tell you that there's danger when there might not be. So I don't know about the redhead thing, but the sensitivity thing is a thing.

[Alie Ward]

Okay. I looked up this flim flam, this weird myth about redheads and anesthesia because it's so annoying that it persists. And I found out, get this, it's true. Research backed. This is real, y'. All. So you can see the 2004 study in the Journal of Anesthesiology titled anesthetic requirement is increased in redheads. They're like, here you go. They found that redheads are more sensitive to pain. They need significantly, in quotes, more anesthesia than people with dark hair. But redheads need fewer opiates. So that was in 2004. What's changed in 17 years? Well, we know now why. So a more recent study found that a certain gene causes melanocytes in red haired mice to secrete lower levels of this protein. It's called pomc. You will not be quizzed. But that protein gets diced up into hormones, including one that enhances pain perception. So they need more anesthesia. And another, another that blocks pain, meaning that they need lower opioid doses. So, gingers, you're magical mysteries and I am honored to pose as one of you. But what if you don't have hair the color of a chestnut horse in the sunset? Well, you could just be a highly sensitive person, which is not a disorder, it's an attribute, it's a trait. And highly sensitive individuals appear in all kinds of species. Species from humans to fruit flies. Scientists say we're all unique little flowers. And some scientists at the Queen Mary University of London do call us flowers, I. E. Highly sensitive. 31% of people, they call orchids. A low sensitive group, 29 of you called dandelions. And then a third group at 40% who have like medium sensitivity, which they say are tulips. I don't know jack shit about botanical robots. Robustness. But I hope that they asked a flower person first or else things could get pretty thorny. I rose to the occasion. And is that like a highly sensitive person? Hsp. I've heard of that, but I wasn't sure if that was like a Thing that was recognized by the medical community,

[Dr. Rachel Zoffness]

you know, being sensitive is recognized as a predictor of pain and chronic pain, development of chronic pain. By the way, trauma, trauma makes your brain more sensitive. Why? Because trauma having trauma as a child, your brain needs to be sensitive. It's adaptive. Like if something terrible has happened to you, your brain is always scanning the environment, your internal and external environment. Like is a bad thing happening. What about now? What about now? Is there danger? Is there danger? So if you have had trauma, your brain becomes more sensitive.

[Alie Ward]

Elise Van Meerbeek wants to know, is there an observed relationship between pain tolerance and gender?

[Dr. Rachel Zoffness]

Ooh, that's so interesting. So what we do know is rates of chronic pain are higher in women. The thing about pain tolerance is I don't exactly know what that word means. It goes back to that super subjective pain scale, that pain rating measurement where, you know, you ask two people or 25 people, you know, does this hurt? And how much? And everyone's going to give you a different answer. So I know that women in general are more prone to developing chronic pain and I don't know if that has to do with sensitivity. That's a really interesting question.

[Alie Ward]

Yeah. I wonder if they've done studies too on people who are gender non conforming and how much trauma that they've experienced too. I'm sure there's quite a bit of that.

[Dr. Rachel Zoffness]

I'm gonna guess there's almost no research on that because not enough research has been done on that. But should there be? Definitely, yeah.

[Alie Ward]

I wish that this had a name. Oh, it does. It's called the Gender pain gap because for many, many hundreds of years, people who were not men were just not included in recent research, which hurts and I want to get real spicy about it. Speaking of Umar Kaku says, can we Talk about the TRPV1 receptor and pain tolerance with spicy foods? Is there any relationship between spice tolerance and pain tolerance? And I have, myself, my brother in law Lee, who is also a heavy metal guitarist, can eat the spiciest foods on earth and none of us understand how he does. Does it? What's happening with spice?

[Dr. Rachel Zoffness]

Great, so the answer is yes. You have receptors in your mouth that respond to touch and heat and sensation. So you have sensors on your tongue that pick up on how hot or spicy a food is. But it doesn't become interpreted as pain until it gets to your brain and your brain inputs all the other information also. So people who can eat extremely spicy food usually are people who have been doing it for a long and they started with low to medium. And over time they worked their way up to super spicy. And guess what's happening? Their brain and their tongue are desensitizing over time. Like being in that room, that dark room and it gets a little bit brighter at a time. So you can develop a really high spice tolerance if you want to using this graded exposure a little bit at a time.

[Alie Ward]

So fun fact. Birds can't taste spicy, but squirrels can't can. Which is why some bird seed is sold laced with hot sauce. So squirrels will be like this. Who am I? Paul Rudd? What is this? A YouTube show about hot wings. But birders say better just to get a squirrel proof bird feeder and to help prevent the spread of bird diseases, make sure to clean your bird feeders regularly, even if it's a headache. Speaking of headaches, a lot of patrons wrote in about migraines such as Rahala, Shay Stamplooski, first time question asker Claire garden specialist Hafer Brea Plum turtle Sarah Carter, Jade Pop Pollard, Paulina Krasinska, first time question asker Rachel Shepherd, Ann M. Madeline Duke Kelly Simone, Sonia Bird, Kelly King and Colleen Heather. Migraine question why do some people like myself and my grandmothers get migraines right before it rains? Do you think that's anywhere in a pain recipe? Barometric pressure?

[Dr. Rachel Zoffness]

It's gotta be. I don't know the data. I mean these questions are so amazing. I don't know the data on migraine and rain but I. So for me I live with chronic leg pain and my chronic leg pain also changes with weather changes. So before rain my leg will also throb. So I've heard people say that that's like, I hate this phrase, like an old wives tale, whatever that means. But I've heard people say that that's not evidence based and I've never looked into the evidence but now I'm going to and I don't know if there's sufficient data to show but it would make sense to me that would be part of a pain recipe because of course there's barometric pressor. If the environment around you changes, it seems reasonable that your PA change too.

[Alie Ward]

I had to look this up and sure enough there's a 2019 study titled Blame it on the weather. The association between pain and fibromyalgia, relative humidity, temperature and barometric pressure. Someone's out there asking these questions. So the short of it is that lower barometric pressure was associated with more pain in fibromyalgia patients and arthritis patients and even people with migraines but the cause? It sounds like a still murky so lower barometric pressure can make tissues expand, which might cause joint pain and migraine. Scientists say that blood vessel dilation associated with the influence of changes in atmospheric pressure can also maybe cause migraines. And lower barometric pressure reduces the amount of available oxygen in the air. But it also usually means shitty weather, which contributes to some psychological factors. Percentage some folks and pain hurts more so apparently Weather accounts for 20% of migraines in Japan. What else triggers migraines? Not much. Just like oversleeping, sleep deprivation, premenstrual period, stressful life events, hot weather, cold weather, relaxation after stress, menstruation, high winds, intense emotions, hunger, bright sunlight, red wine consumption, food additives, msg, night nitrates. Also, serotonin changes can open and constrict blood vessels. If you've had migraines, you might be chuffed to learn that they're the most common neurological cause of disability in the world, according to a 2017 study which also taught me the ology of migraine pathophysiology. Yeah. Future episode, anyone? My brain says, hell yes. No question. Speaking of, this next question about emotional pain was asked by 4 million million of you whose names I will read quickly and hopefully correctly. Nicole Kleinman, Chelsea Rabble, Siena Da Costa Pinto, Kayla Clark, Danielle Boris, Anna George, Brooke Zimmerman, Michelle Husko, Mrs. Pye, Shmiti Thompson, Allen Lee Pomgren, Florpin M. Shaelyn Clark, Sid Timothy Huang, Dora Peregrine, Anne Dohlmeyer, Maya Rohr, Alia Meyers, Lee Earl of Gramalkin, Julie April, Jade Bauckham, Randall Ashley Okey, Andia Negrit, Robin Parks and Scott Shelton. Great question. Is there chemically a difference between physical and emotional pain?

[Dr. Rachel Zoffness]

Oh my God. That question makes me so deeply happy. There are these wonderful, wonderful researchers who study social neuroscience. I'm going to answer your question in a roundabout way. And they studied the neuroscience of social exclusion and being ostracized. The science of ostracization, which is a very hard word to pronounce.

[Alie Ward]

Ostracization.

[Dr. Rachel Zoffness]

And they found, found that social and emotional pain maps exactly onto the parts of the brain that process physical pain. So is there a difference? Yes. Do they overlap and affect each other 100% of the time? Yes. Does emotional pain hurt physically? You know, it does. Like, ask anyone who's going through heartbreak how their body feels like you have chest pain pain when you are heartbroken. So emotional pain and physical pain always, always, always are connected in the brain.

[Alie Ward]

So, yes, physical and social pain Overlap in an area of the brain called the anterior cingulate cortex. And yes, Jade Balcombe Randall and first time question asker Carrie Anderson. Pain relievers can soothe broken hearts or at least smooth ruffled feathers. So for more on that, you can see the very directly titled Acetaminophen Reduces Social Pain. Fmris showed that acetaminophen reduced neural responses to social rejection. And I don't know how they tested that, but I hope they were nice to the volunteers. So, yes, pain relievers, or better yet, CBT might help when you're feeling butthurt. Now, aside from your crack, how about your back? First time question asker Jacob Leftwich, Amy Naramatsu, Pixie Muffin, Fuzzy Goddess, Isle Van Meerbeek and Savannah bigley all have 99 problems, and a back is one. It's funny because it's like looking at Instagram, you might as well actually be hitting yourself in the face with a frying pan. You might as well just do that.

[Dr. Rachel Zoffness]

Amazing.

[Alie Ward]

That was amazing. It does hurt. Now, Michael Swords wants to know, when it comes to back pain, how can we get rid of it? And I feel like I know so many people in various levels of athleticism and age that have back pain. What's going on there?

[Dr. Rachel Zoffness]

Back pain is one of the most common types of chronic pain. And the answer to your question is if you're not treating it in a biopsychosocial way, your back pain's gonna stay exactly the same. So if you ask every single person you know how they've treated their back pain, I'm gonna bet a bazillion dollars, which I don't have to give you, but I do have the capacity to receive that. They have been told to treat their pain with medications and potentially surgeries. And check this fact out. Ready? There is a new syndrome in medicine called failed back surgery syndrome. That's right. They've given it a name. And in that highlight, beautiful example of when you treat pain, purely biomedically, chronic pain in particular, it is not going to work. And by the way, that's not to say that back surgery doesn't heal people. It surely does. And there's lots of things that can go wrong with the back. Totally. But pain, chronic pain is processed by the brain. So we have to think about the whole person and the whole picture. So if someone's living with chronic back pain and the pills and the procedures have not worked, the answer is, let's go after the other things in the pain recipe to figure out what's going on. Great.

[Alie Ward]

Answer. Tabitha White wants to know, why do some people hold their breath when experiencing high levels of pain? Asking for me.

[Dr. Rachel Zoffness]

Love that. Right? So if you remember that pain metaphor we were talking about, this volume knob that operates. One of the things that happens when you have pain, believe it or not, is that stress and anxiety go up. If you ask human beings in general, what are the biggest stressors on human beings, like death of a loved one, moving. But pain. Pain is one of the biggest stressors on a human being. It's so stressful to be in pain. So we do these things, like we clench. Sometimes we don't even know we're doing it. So we clench our whole body.

[Alie Ward]

Body.

[Dr. Rachel Zoffness]

Or the part of the body that hurts. And we guard. And sometimes we limp or we change our posture because pain is miserable and you're trying to do everything you can not to have it. So holding your breath is a pain behavior. It's a clenching. It's often involuntary because pain hurts, which is the most basic thing I've said all day. Pain hurts. So you're clenching and you're trying to fight it off. And the irony there is, as we know from the pain dial, the more you clench and the more tense and tight your body is, the higher your pain volume is actually gonna be. So I know. So somehow finding a way to help your body relax and be calm is actually one of the things that we're gonna need to do to help pain. And by the way, easier said than done. I'm not just saying like, oh, be relaxed. Cause that's not a thing like, oh, I hate that when people are like, oh, just relax. So it's not just that it's more complicated than that, but the tensing and the tight, tight tightening actually is going to make pain worse.

[Alie Ward]

That makes sense. Quinn west had a question. If you take medication that blocks pain signals, is the pain still there? This is kind of a philosophical question.

[Dr. Rachel Zoffness]

Great question. So I'm going to answer that with another question. If pain is produced by the brain and you're blocking the messages in the brain, are you actually blocking the pain messages? I think the answer has to be yes, because you're blocking the messages that your brain is interpreting as pain. So the sensory signals coming from the body are not yet pain. So the sensory message is coming from the body. Whether it's like a broken foot or a bad back, it's not pain till it gets to the brain. It's just sensory information. So when you target the brain in your treatment. Yes. You're blocking the ability of the brain to interpret that message as pain.

[Alie Ward]

Okay, so a lot of folks such as Roberta, Amalia, Conti, Cheese, Leanna Schuster, Alice Claire, Dori Kaufman, Brent, Ben Mafis, Michelle Jacobs, Leela Weller, Lindsay Mixer, Catalina, first time question askers, Kelly Shaver, Andrea Cassidy, Ed Ross, Monica Sweet and Molly had questions about fibromyalgia, which is a disorder that causes pain and tenderness all over the body. It also causes sleep problems and fatigue. In my opinion, it sounds not fun. Heather Circle wants to know, for those experiencing symptoms of fibromyalgia, what are some good tests to request from doctor?

[Dr. Rachel Zoffness]

There are no good tests for fibromyalgia. So diagnosis of fibromyalgia has been a shit show. There's like lots of different ways of diagnosing. It's like certain number of body parts has to be in pain. But as everyone with fibromyalgia knows, different parts of your body hurt in any different given moment. So if you only have pain in eight body parts tonight, does that mean you don't have fibromyalgia? So there's no real great test, is the honest answer. But if you're living with fibromyalgia, you absolutely have a biopsychosocial pain recipe, and we need to figure out what that is. And again, I always want to talk about the stigma around recommending psychology for the treatment of pain. I live with that stigma every day. I always recommend psychology for everybody living with chronic pain. Why? Because if you're not targeting the brain, you are not targeting pain. And psychology really goes down the rabbit hole of what are you thinking, thinking, how are you feeling and how are you acting? So I would honestly, from the bottom of my heart, recommend a pain psychologist, or even any psychologist for people living with fibromyalgia. In addition to all the other things you're doing, PT and OT and going for walks with friends and doing fun things and baking brownies.

[Alie Ward]

So some pharmaceutical therapies for fibromyalgia are actually also used for neurotransmitter balance and the brain's ability to tamp down pain signals. Researchers have even tried low doses of naltrexone, which is prescribed for alcohol use disorder and opioid use disorder. But in many studies, cognitive behavioral therapy provided what researchers call worthwhile improvement in pain related behavior and coping strategies and overall physical function. And they noted that, quote, the beneficial effects of CBT can be achieved in 10 to 20 sessions, compared with many years required for classes. Classical psychoanalysis. So CBT has also been shown Effective for reducing neuropathy pain and improving pain interference and mental health functioning. So retraining your actual brain to just tell those pain signals to cool their freaking jets, please and thank you. And Rachel says, this is so exciting because of neuroplasticity. So in an email after our interview, she added, the fact that the brain is always changing means that the brain can change change. And if the brain can change, pain can change. Which is good not only for pain havers, but for the people who love them. Like Megan Stingle, who asked, when someone tells me about an injury, why do I sometimes feel a vague sense of pain in that part of my body? Well, they're telling me a story. And another patron echoed that. Stacy Sellowitz asked, is sympathy pain real? Do twins feel it more, or is it more likely for people who consider themselves empathy.

[Dr. Rachel Zoffness]

Oh, my gosh, these questions are lighting up my brain. Yes, sympathy pain is real. So they do these studies in neuroscience where they look at a mother's brain and a child's brain, and if the child is suffering and experiencing pain, the mother's brain, the pain pathways in the brain light up as if she's in pain. Which is why moms have such a hard time tolerating their children crying. Right. It's just. It triggers you in that way. So, yes, we have mirror neurons in our brain and we do feel other. Other people's feelings. Anxiety contagion and emotional contagion are real. And yes, if you are someone who is empathic or an empath, I'm going to tell you what that means. It means your brain is really, really, really sensitive and you pick up. You pick up on things other people can't pick up on. So you feel other people's emotions when you walk into a room. And I'm going to bet a lot of money that you're an empath. A.L.I.E. ward. Yeah, totally. Right, Right. So it means our brains are more sensitive, so we're more likely to pick up on other things people are feeling emotionally. But the downside of it is that we're also more likely to experience chronic pain.

[Alie Ward]

A lot of people who I will listen aside, Mariana Hulson, Danae Dryden, and Ashley Holm, want to know how touch inhibits pain and if scratching or applying pressure helps alleviate pain. What's happening?

[Dr. Rachel Zoffness]

I want everyone to know I'm doing a dance of joy in my chair. So I mentioned back in the day when I was a nerdy undergrad that one of the things that really excited me about pain was this thing called the gate Control theory of pain. And the gate control theory of pain is just this nerdy neuroscience. It's like back in 65, these guys came up with this gate control theory of pain, and they forever revolutionized pain science. And it's still evolving. There's the neuromatrix theory of pain now, and there's all this other cool pain science. However, what we know about pain is that touch does actually gate pain. So back to our metaphor of this pain dial. So, like, for me, I remember this really resonated with me. My professor said you bash your knee. Like you're sitting under the table and you bash your knee. What's the first thing that you do? Yeah, you rub your knee. And the reason you rub your knee is because touch messages get up to the brain faster than messages that code code for the sensory information that codes for pain. So touch is actually one of the things that can lower your pain volume. So one of the things that can be on a low pain recipe for people, by the way, is getting massages and hugging people and sensory things that really make you feel soothed and calmed, like a Snuggie or a really lovely blanket or a dog. But yes, touch. So touching the part of the body that hurts will actually help your pain.

[Alie Ward]

Huh? So adopt a dog, you got.

[Dr. Rachel Zoffness]

Yeah. Or like, rub your bash knee. Or get massages. Back massages or. Yep.

[Alie Ward]

Maren Ellis, first time question asker asks, why do we forget pain? I've had three babies with no meds, but I have forgotten the amount of pain I was in with each and gladly had the next. What is happening there with really, really intense pain?

[Dr. Rachel Zoffness]

So there is research on childbirth pain, and that is a unique kind of pain. And the research shows that after giving birth to a baby, you are flooded with all these wonderful, delightful chemicals. It's like a bath for your brain. It's like oxytocin and. Which makes you feel connected. And dopamine, which is like this reward chemical. And serotonin, which makes you feel happy and joyful. And endorphins, which are your brain. Brain's endogenous, natural painkillers. And so your brain takes this lovely bath, and it feels so good, and it connects you to your baby, but it also changes your memory of childbirth. But why is that adaptive? Because we're supposed to procreate. I'm told that's part of, like, you know, the genetic pathway. So if childbirth is so aversive or terrible that you never wanna do it again, we might go extinct.

[Alie Ward]

Yeah.

[Dr. Rachel Zoffness]

So your brain does this, like, Funny trick, but that is not true for many other types of terrible, terrible pain. And ask anybody who's been in a car accident or like some terrible trauma, they have not forgotten their pain and their body has not forgotten their pain either.

[Alie Ward]

Yeah, I guess, like with Jarrett's knee surgery, it's not like his knee's gonna suckle for the next year. You know what I mean? Who knows?

[Dr. Rachel Zoffness]

You never know.

[Alie Ward]

I thought this was a great question from Val McKelvey. How well does marijuana work for pain relief as compared to traditional pain relief medicines, like all of the CBD that's on the market, the thc, things like that. Good for pain, not good for pain. Somewhere in the middle.

[Dr. Rachel Zoffness]

Here's the complicated answer. I think the thing that we know now is, like, with pain, it's always a complicated answer. So here's the complicated answer. Research shows that the chemicals in marijuana can actually lower pain volume. Righteous. They can. Here's the problem. Marijuana, and I am not opposed to in any capacity, also can do funny things to sleep in not a great way that can negatively affect pain. And the thing that actually is most concerning for me is the patients I'm working with who are using it as their only pain management strategy and nothing else. So if you become, if you lean on any one thing, it doesn't matter what the one thing is as your primary or only coping strategy for pain, you're targeting only the bio domain of pain. And there's a lot of things contributing to anybody's pain recipe. So if we're just solving it with weed, we're not actually addressing that big, complicated problem that's contributing to the pain. So the answer is yes, science shows it can lower pain volume, raises pain tolerance, whatever that fancy word means. But there's also a couple of other complicating factors. I do think it's great for things like cancer pain because people can't eat. But that's also sort of a problem because with overuse of marijuana, you can stop eating. There's like an amesis syndrome that develops where your stomach doesn't want you to eat any more food. So what is my tldr? Yes, it can be useful short term, not all day, every day, and not as your only strategy.

[Alie Ward]

Cool. Last listener question. Danielle Larman, Alia Meyers, Lux and Ari B. Want to know in Aaliyah Myers words. So what's up with masochism? Asking for a friend. Perhaps their friend was one of these patrons. Chris Bauman, Piper, Dhonielle o' Neil Lux, Our R E B Mikayla Quant, who asked, why does it make me so horny? Or the wonderful Scala Borealis, who responded to that. I spent several minutes trying to type this out in a concise way and saw this comment and was like, yeah, that's pretty much what I was trying to say. Also, Danielle Larman, why do I like pain? Please tell me why I'm so weird. Masochism and recreational pain seekers, probably not

[Dr. Rachel Zoffness]

so weird, not weird. Also, such a delightful question and I'm so glad we get to touch on it before the end of this because I really wish I had even said this sooner. Pain is a subjective experience. Like when we're talking about the definition of pain that should have been in there, it's always subjective. And like we said, context and environment matter. If you're choosing it, it's gonna change your experience. If someone punches you in the face and you're not expecting it and they're stealing your purse, it's gonna feel very different. Or slaps you, it's gonna feel very different than in the context. Context of sex or like you're turned on, you love your partner, you trust them or whatever, or you just. You want it. So context, environment, all the things are always going to matter when your brain is interpreting the message. So yes, pain can be pleasurable. Of course, that's super normal and human. It's not weird at all that for some people, some of the time pain is pleasurable. And again, back to that thing like you stub your toe on a really bad day when you've been fired, it feels very different than you stub your toe, you're out with your friends, eating ice cream. So always the context in which the messaging happens determines how your brain interprets the signal.

[Alie Ward]

I want to make sure we're still.

[Dr. Rachel Zoffness]

Did I make sense? Did that make sense?

[Alie Ward]

Absolutely. Sometimes I just. I love the interview so much. I make sure we're still recording because in my nightmare we've somehow totally.

[Dr. Rachel Zoffness]

It's not recording.

[Alie Ward]

The batteries have. Now, the thing that sucks most about pain, what is it? What sucks so much about your job? What sucks about pain? What's frustrating? Frustrating. Vent it out.

[Dr. Rachel Zoffness]

The thing that sucks most about my job is the stigma associated with psychology and pain. Like that thing where people think you're saying they're mentally ill. That drives me mad. The thing that sucks most about pain is the lack of agency and control we feel like we have over it. And we feel that lack of agency and control because no one has ever explained pain to us. Why has no one ever like When I was like a 12 year old kid with stomachaches, why didn't anyone ever say, by the way, this might be mediated by anxiety and stress. And by the way, it was like I was so socially anxious. No one ever explained to me I was like poked and prodded and blah, blah, blah. No one ever. Why? So that, as you can tell, infuriates me.

[Alie Ward]

Flames, flames on the side of my face.

[Dr. Rachel Zoffness]

Who doesn't deserve to understand pain? It's a ubiquitous human experience. We are all going to have it. None of you are going to get away with not having pain. So we might as well know what it is and know what to do about it. What also infuriates me about pain medicine is the way that nobody gets educated about it. So Here's a fun 96% of medical schools in the United States and Canada have zero, and I mean zero, dedicated compulsory pain education. So if 96% of our doctors are not learning about pain, who then knows about pain? So of course we have an opioid epidemic. Of course we're throwing pills at pain. Like the people who are treating pain aren't being adequately educated. It's nobody's fault. It's just a really broken system. And in psychology programs we get zero pain education. Also in PT programs and OT programs, a lot of providers will tell you insufficient pain education in nursing programs. So it's like if you think about this as a trickle down phenomenon, like our providers are the first people we see and if no one's ever explained pain to them in this way, where it's a biopsychosocial phenomenon, how are they ever going to tell us?

[Alie Ward]

So side note, in addition to being a clinical psychologist, Dr. Zofnus is also a researcher and a lecturer at UCSF. And she and her colleagues there conducted a six part pain training with UCSF doctors. And in a study just published in June, they found that 90% of the physicians said that the pain curriculum changed the way that they conceptualized and approached or managed pain. 90% said it changed the way they did it. So the conclusion, she said education matters. Yeah, especially when it comes to doctors. You want them to eat books? School up. Thank you so much.

[Dr. Rachel Zoffness]

So in my mind, if we're ever going to target the opioid epidemic, if we're ever going to target effective pain management, we have to start with education. Which is why chase people, people like you, because how do you spread the word? Like, how do you tell people, by the way, there's hope for treating your pain? We just have to do it differently.

[Alie Ward]

Yeah. I think you should be the Brene Brown of pain management. Okay, great. Yeah. I feel like the typical thing we're used to seeing is just a laminated placard on the wall with a series of emojis.

[Dr. Rachel Zoffness]

Yeah, totally.

[Alie Ward]

That's pain education for doctors.

[Dr. Rachel Zoffness]

You got it. So what Ali's talking about is it's called the pain scale. It's actually called the Faces pain scale, and you've probably seen it before. It's like, I think it's 0 to 10, not 1 to 10, but I can't remember. But it's all these faces that show how much pain are you in? And have you ever read Hyperbole and a Half?

[Alie Ward]

Yes. Yes.

[Dr. Rachel Zoffness]

Allie Broch. Am I saying her name right? I don't know. I love her. That girl is so brilliant and so talented. And Allie Bro. She probably listened to this podcast.

[Alie Ward]

I wish.

[Dr. Rachel Zoffness]

Is it Allie Broche? Am I saying it right? Okay.

[Alie Ward]

Or brosh? I have no idea.

[Dr. Rachel Zoffness]

Okay. So she. If you Google hyperbole and a half pain scale, you will laugh your ass off. She revised. I use it in my lectures. She revised the pain scale? Yes. It's. I think it's 0 to 20 and 20 is like this face. Like, the eyeballs are falling out and blood is coming out of the ears, you know, and she also redoes, like, this 0 to 10 pain scale, and she's like this. This is just not accurate. Like five looks like, you know, I got Ben and Jerry's cookie dough ice cream and there just isn't enough cookie dough in it. Yeah. Like the faces don't adequately convey what the experience of being in pain. Her pain scale is infinitely better. Allie Broch, Hyperbole and a Half pain Scale. You will laugh. And only a pain nerd would really know that there's a better pain scale out there. Written by the author of Hyperbole and a Half.

[Alie Ward]

Well, what about your favorite thing about what you do?

[Dr. Rachel Zoffness]

Oh, my God. So, absolutely, this is the most addictive work I've ever done in my life. And I also feel selfish doing it because that kid who had been in bed for four years, when that kid stood on stage and went off to college, I felt so rad. And I am not performing magic. You know, this is something I was trained to do. It exists in books. The knowledge is out there. I'm just a conduit for the thing that already exists. But when people get better and they get their lives back. This kid got asked to prom by two girls. Not one, but two. And it's just like, so delightful to see people re engage in the world, get their lives back, and feel like they have power again over their bodies and their lives. That is like, I will never do anything else. It's like the most addictive thing I've ever done. And people write me these crazy emails that make me cry. Just like, yeah, if I start talking about it, I will cry. It's just crazy. The work changes lives. And it's not. Again, it's not me. I didn't make it up. But, like, this work changes lives. And I just want to say the other thing that makes me really infuriated about pain is that it's not what I do is not affordable to everybody. A lot of people can't afford pain psychology because insurance doesn't reimburse it. And that's actually why I stuck everything that I do into a book for 20 bucks. Because pain education and pain medicine should be affordable and accessible to everybody. Why is it only affordable by a few people? That's crazy pants. So the pain management workbook, which I gave you literally is intended to be like, you don't need insurance coverage. It's $20. Everything I'm talking about is in there. Again, it's not magic. And it shouldn't be unaffordable for anybody. Is that the word?

[Alie Ward]

Yeah, absolutely.

[Dr. Rachel Zoffness]

It makes me so mad. You can tell. I just. I feel like I love it. Yeah. Like, why is treatment only for people with money?

[Alie Ward]

It's nonsensical.

[Dr. Rachel Zoffness]

Finances. Drive. Pain management. How is that? Okay.

[Alie Ward]

Bonkers. Any one piece of advice that you want people to know to keep them going?

[Dr. Rachel Zoffness]

Yeah. Pain is treatable. You do not need to be alone on a pain journey. A lot of people are suffering alone. There's a lot of support available. Pain psychologists, there's not many of them. Again, because just psychology programs don't train us in pain. And they should. And it's a problem. So this is a call to action for anybody in the world of psychology and in medicine to up your game when it comes to pain education. But a couple of solutions for people who are suffering alone. You can Google pain psychologist near me. There might be one. Psychology Today has people on there who list chronic pain as one. You want to find out if they're trained in cognitive behavioral therapy. If you have a therapist you like or you're willing to find a therapist you like, hand them the pain management workbook or any pain management workbook. There's others besides mine out there. It doesn't matter. And ask them to go through it with you. You don't have to go through the journey alone. It's isolating, it's miserable, it's painful. And support is available and help is available and change happens. Pain treatment is totally, totally possible.

[Alie Ward]

Thank you for being on.

[Dr. Rachel Zoffness]

Thank you so much for having me. This is so cool.

[Alie Ward]

Seriously. Brene Brown of pain, I'm calling it rad. Oh, so for God's sake, ask smart people doofy questions because your brain can learn from the things that their brains learn from other people's brains. And I hope that this episode helps anyone with pain get better care, helps loved ones understand that pain is real and give some hope and maybe some alternative approaches to turning that pain dial down. So Dr. Zoff sells her workbook for 20 bucks. It's on Amazon. It's where we get books. It's probably in libraries near you. And she wants to make it cheap and accessible for everyone. And of course now in 2026, her big book release so find Tell Me Where It Hurts the New Science of Pain and how to Heal wherever you get books, absolutely life changing and hers is a name that you're going to continue to hear in this space. She's uncovering the science of all the things that make you feel alone and confused and in pain. And she's amazing. You can follow Dr. Zoffsoffness on Twitter and herealdoczaf on Instagram. Her website is zofnus.com, and those will all be linked in the show notes as well as links to the Trevor project and the sponsors you heard about. We are Ologies on Twitter and Instagram. Those Twitter handles, you can just find them on Bluesky in 2026. I'm Alie Ward with one L on both. Please say hi. More links are always [e-mail] ologies dology for this one. Thank you to Aaron Talbert for admin in the Ologies podcast Facebook group. Thank you to new bride Bonnie and Shannon of the podcast. You are that for helping with the merch. Noelle Dilworth and Susan Ha Hale for all the scheduling and behind the scenes business. Thank you to Emily White of the Wordery who makes our professionally done transcripts. Caleb Patton who bleeps episodes which are up for free on our website. Zeke Thomas Rodriguez for the Smallogies episodes which come out every other week. They are kid safe classroom friendly now with kids safe ads as well. Thank you to Kelly Dwyer for the website. She's available to make a website for you if you like her links in the show Notes. Thank you to Nick Thorburn for the thank you theme music. Thank you to Jared Sleeper and Steven Ray Morris, who endure the biggest pain of all, which is me, and I appreciate them so very much for it. Also, thank you to our new editors since 2021, who have joined the wonderful Jake Chaffee and Mercedes Maitland of Maitland Audio, and of course, managing director Susan Hale and scheduling producer Noel Dilworth. Still with us because they're the best. And if you stick around to the end of the show, you know, I tell you a secret, and this week's secret is that I like to burn incense sometimes. And I love when you're burning an incense stick and then suddenly you start smelling the burning stick itself, like the little bamboo stem, and you're like, oh, that marks the end of this incense stick. Thanks, nose. And that. Unless you're my friend Micah, who can't smell anything. Sorry, Micah. Also, I still love incense, even though I try to burn it with more windows open because it will eventually probably kill me, unfortunately. But my favorite scent lately is this incense. It's called papier d', armenie, and they're papers. You tear off a little strip and you accordion fold it and you light one side and let it smolder. And it smells like myrrh and vanilla and woods. And it's called papier d', armenie, like D apostrophe of Armenia. And the scent is armeny. So good. Sometimes I just keep the little booklet, my purse, and I take it out and I huff on it when I'm in need of something to cheer me up. So, yeah, papierre d'. Armen. So, yes, papier d'. Armenie. I'm sorry, Micah. It's an olfactorial delight. Okay, bye.

[Dr. Rachel Zoffness]

Bye.

[Alie Ward]

Pachydermatology, homeology, cryptozoology, lithology, nanotechnology, meteorology, cold factology, naphology, serology. I'm a doctor.

[Dr. Rachel Zoffness]

Tell me where it hurts.

[Alie Ward]

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