When Chronic Pain Takes Over Your Life | Dr. Ravi Shah

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What we want to do is reduce the pain by 10% here and 5% here and 20% here and move things in their life so they get a little more functioning there

and it gives them a reassuring sense of control that their body might feel like it's on fire and they can't get out of the building but actually they can calm things down a little bit.

Absolutely.

Hi, I'm Dr. Jason Seaferman and welcome to Care Beyond the Pain. In each episode, I will sit down with a provider, a person with pain, or a supporter to explore their experience and share their perspective on the pain journey. Together, we will navigate care beyond the pain.

Hi, I'm Dr. Rabi Sha, a psychiatrist. Wonderful. Dr. Shaw, thank you for joining us today. It's so great to have you. Uh, we've had the experience of collaborating on many patients over the past few years and have gotten to know each other. uh professionally in that sense. I really want to hear how you got into pain.

Great question. Um naturally through the kinds of patients that we've shared, I mean my experience is that people when they've been on a long pain journey, especially they've seen many doctors, they felt either unheard or lacking in answers eventually become really emotionally distressed as well. And I think they're a lucky few who have some guide around them who says you know maybe there's something to talk about here as well. And um people who come to me I think they come with a lot of frustration with a lot of hopelessness and pain has sort of taken over their lives.

And part of my job is to help them understand how they got to where they are. um what they can do in terms of working with their medical team and their pain doctors and everybody else about where to go and and start to build a life um that they actually like moving ahead. There's a lot to unpack there. A lot of patients with pain with chronic pain especially have been around the block.

Yeah.

They've seen a number of different providers. Every provider is a little different. Some will tell them that the pain is just in their head. Others don't give them good answers. uh how do you go about let's just say you're meeting a patient for the first time. How do you come to understand and how do you help the patient understand that you understand what part of their pain experience is actual pain is the body's response to pain and is medical trauma medical PTSD due to their engagement with the health care system.

Well, if we can get that far in a first session, I'm very proud of myself because it's a real challenge to to do that. And I think what I really try to start with is just helping them feel heard. That goes a very very long way in opening up um their feeling of being heard by me that that I believe them that that there is something going on with them. Um and then from there we can start getting into well like what's going on in your life and and how are you approaching this pain?

what are the things you're doing that are helping and what are the things that are sort of reinforcing the pain. So then that opens up that second piece you're talking about which is there's the literal cause of the pain but then there's all the ways their life is starting to revolve around pain and your life revolves around pain then all of a sudden your life starts to feel smaller and smaller and smaller. Can we talk about that a little more because there's wi with the chronic pain there's a large part of their life that they can no longer engage with.

They may not be able to work, go out socially, do things that brought them joy and their day is now filled with doctor's visits and physical therapy and you [snorts] know staying at home because they can't get out. So it's hard not to revolve around the pain. How how do you intervene?

Well, you you start with wherever you can and and I tend to take a very pragmatic hybrid approach because on the one hand you need to understand where they are. You cannot push people too hard, but at the same time, you try to look for little windows or little opportunities of where they could do just a teeny bit more and trying to help them build some type of small victory. So, for example, you know, you and I shared a patient who whose whole life started to revolve around using the restroom.

Um, and they felt like they couldn't do it outside of their house. And so, their whole routine, day, week, vacations, flights, everything revolved around the timing around going to the bathroom. So when you're starting a treatment like that, you can't sort of tell them just like forget about it, get out of the house. That that's not going to be very practical. But what you do try to do is say, okay, you're going to do your routine. You need to have the whole morning at home.

What are we doing in the afternoon? Okay, how do we start to get you to open up just a little bit? And then we'll start trying things, but in like a very slow, graded way where they have control, full control. So, it's very very important for folks who have felt either loss of control through the pain or loss of control through everybody else telling them what to do. Um, but sort of gently guiding them to say, "Well, how can we open up your life?

Like, what would you like to be doing with your time?" And and starting to give them some early victories.

I feel like we we jumped into the depths real quick. Yeah. Is is there anything that you think is important to explain at a more superficial level if if we have a patient listening that maybe hasn't thought about all of this in that depth? I think just to say that you have to start thinking about pain in in as a multi-layered concept. Um there is of course the literal thing that's causing the pain. But if you only look at it like through that lens um and you and it's starting to make you know your whole life is revolving around pain you're probably you know doing yourself a bit of a disservice.

And when you open up, it's hard to say. There's pain, there's how I'm thinking about pain, how it's kind of affecting my overall life, and then there's, by the way, this whole other element, which is how it's affecting my mood, my emotions, how anxious or preoccupied I am with my pain. And all of these things keep the whole system going. And so, what you want to do is sort of pause. And I think is one of the reasons people like get a lot of benefit out of coming into a therapy is to just start to unpack all of that and see this whole big thing for what it is.

But then you can break it down and start start making steps. So to you know superficially to answer your question is we have to understand the whole thing but then you know a patient might say like so what like why why and the answer is because then once we can break it down it doesn't have to feel so overwhelming.

Yeah. It's like any complex problem that needs to be solved. If you can identify the steps, the layers, make a checklist. It's it's kind of funny to think about psychiatry as as layers to unfold. That's how I think of mechanical pain, right? Uh so that that's a really interesting methodology to think about. Uh I I would love to hear more. Uh let let's talk about the the identity piece of it. So you you mentioned their life gets smaller focused more around the pain.

I've noticed a lot of patients will take on the identity of their diagnosis. I think I think some of it's because they've searched so long so hard they want answers so badly they finally get something that seems to describe their situation and it's almost like the magic key that will open the door to the right treatment for them. But that's not always the case. It's often a misdiagnosis. It often leads them down the wrong path. How do you think about self-identity and how pain affects one's one's sense of self?

Yeah, I think it's a really complicated thing. I've seen many folks with this type of situation where, you know, they have this image of themselves um I'll give you a totally different patient. um sort of a middle-aged father of of adult children, robust social life, you know, um you know, very accomplished at work, sort of had this whole image of himself as this very high achieving person. Not to say that's not true, that was absolutely true. In comes a chronic pain diagnosis, right?

And as it chips away and chips away his ability to do things, it it kind of puts a person in a bit of a quandry. Am I the high achieving I do a lot of stuff or am I a chronic pain patient and and sometimes they have to pick the chronic pain patient as a way of explaining to their community and themselves why are they not functioning like they were before and I think that's why they feel sometimes like they have to as you said take on this pain identity and part of our work is starting to say wait a minute wait a minute that's not really going to lead you down a very successful path it's kind of understandable how you got there but we need to start rethinking and and reimagining yourself as yes, you're a high achieving person who also suffers from chronic pain and here are the things we're doing about it.

So we have to kind of get a more nuanced view of of the self.

It's very practical, very divide and conquer. So holding both of those things in mind at the same time,

right? So I I hear what you're saying about the pause and the value of of the session where you can do that. Um I' I'd never thought of psychiatric treatment in that way which is which is a brilliant insight. Uh how do you help patients find or develop tolerance for the uncertainty while they're holding these two things in mind while they have hopes and dreams? Yeah, it's tough. It it's really tough because um people are looking for answers and and in so much of medicine we have really awesome answers.

Um, but pain is an area where sometimes we do and sometimes we don't. Or sometimes the answer is complicated and broad, which is to say, we can get you a lot functionally better and back on your feet, but is your pain going to ever kind of disappear entirely? Maybe not. And tolerating that degree of uncertainty and the uncertainty of the course is really, really difficult. And in part, what we do in our work um a phrase we use is um we bear witness.

And when you sit with someone and you bear witness to their challenges and their um their difficulties in just an honest and compassionate way, then they are somehow almost magically able to tolerate things that they couldn't otherwise. And that that's a huge part of what we do.

Can you talk to us a little bit about the sympathetic nervous system?

Yes.

In in pain, you know, it's it's a reinforcing factor for sensitization in the body, especially visceral pain, headaches, things like that. But in your field, there's a lot of post-traumatic stress and and once that system is activated, especially when it's activated with pain, of course, the fight orflight response to the brain is also active. Y tell us about your approach to this.

Yeah, I talk about the sympathetic nervous system at least several times a week, if not every single day. I spoke about it today and you know one of the things I remind people is that you know you've got the sympathetic and the parasympathetic nervous system and they need to be in kind of a balance in all of our bodies right and when the sympathetic nervous system is in overdrive which commonly happens in yes traum traumatic disorders PTSD anxiety disorders panic disorders but also in pain then what happens is our our brain starts to kind of dial in and get really focused on um the thing that's causing this sympathetic overdrive But that to your point starts reinforcing the pain and keeps the whole loop going.

And so one of the big challenges in um and one of the benefits of getting into a psychotherapy or or or seeing a psychiatrist is saying, "Hey, hey, what can we do to start beefing up our parasympathetic nervous system and there's medications we use that do that. There are some medications that have a dual FDA approval for both pain and anxiety. And I think one of the mechanisms for that is that it's helping um sort of rebalance towards the parasympathetic nervous system um that that I use commonly in the kinds of folks that we treat together.

Um but also there's things that you can do in your own body um to actually start to take control and move your par your parasympathetic nervous system to the to the forefront. So, there's deep breathing exercises, there's guided meditations, there's progressive muscle relaxation, which is a huge thing um I especially like to do with folks um who have either chronic pain or other physical ailments because

it gives you a feeling of control over your body and control over your nervous system. I think that people in this category are craving that kind of control. Um and it gives them a sense that you can actually drop your own blood pressure and heart rate by yourself. I think that's very empowering to people. Um, but if we can kind of, you know, get the gas pedal off of sympathetic nervous system a little bit, it can go a very long way to helping them start to get um, better emotionally and also to reduce their experience of their pain.

I I like that framing because patients in a pain state often feel out of control. Yeah. They've lost control of so many aspects of their life and their body. A lot of patients that I work with, they say, "Oh, yeah. I tried the deb breathing did I did the CBT. It didn't work for me. But I I almost think that if it if we see it in this framing of that's one tool for them to regain control of their body, they can assert control over their heart rate, over their breath.

Yeah. And and of course we know this changes the physiologic responses. I I I think I think this framing might help those patients engage in these exercises more seriously.

Yes, I think so too because part of what you're trying to help them understand is that, you know, there's not in many of these cases, they're not going to be a silver bullet solution. What we want to do is kind of um reduce the pain by 10% here and 5% here and 20% here and move things in their life so they get a little more functioning there. All of a sudden, people have been debilitated are getting 40, 50, 60, 70% of their life back.

I mean, that would be nice, right? I mean, even if the pain doesn't change, but the physiologic response dampens a little bit, if that body anxiety calms down a little bit,

that that opens them up to then engage a little more with their kids or a little more with work.

Yeah. And it gives them a reassuring sense of control that their body might feel like it's on fire and they can't get out of the building, but actually they can calm things down a little bit.

Absolutely. And and it gets at this other issue which is sort of related, but is maybe a slightly its own paradigm, but for many folks, the pain is very preoccupied.

It's all they're thinking about all the time, when they're going to have it, when they're not going to have it. Well, that's not a very fun life to live for most people. and it's very very unpleasant. So if you can start to give people a sense that um there's some control over it that you can modify it then they start to feel like they can actually think about something else besides me.

Yeah. I mean the pveration itself is sensitizing.

Yes.

Uh I I sometimes tell patients they just have to have a learned apathy.

Like yes the pain's there. I hear you. I see you. I know what you feel like. Yeah. Yeah. Yeah. But I don't you know it's it's the it's the concern. I mean, it's the normal emotional response to a pain signal to be concerned, right? Because there's something wrong that's sending that signal. So, of course, it's completely natural to feel that way, but recognizing that we do understand what's happening. I mean, assuming we know what's happening with that particular patient, that you know, you don't need to have a panic response every time you feel the pain.

You know what it is. We're doing something about it. We have a plan. Right. Going back to what you said about that that constant fear and the lack of control, a lot of patients will reach for an escape mechanism.

Uh you know, a lot of times it's a pill, it's a medication. Uh and this is how the opioid epidemic started in part. Not blaming the patients for this. It's, you know, definitely the doctors not knowing what better to do and giving out a lot more opioids than were necessary. But then a lot of patients do find themselves in a situation where they have a feeling and their reflex response is to reach for medication.

Yeah.

Which does have a role and we use lots of medications for lots of different reasons. But the mindset of having a reflexive response to reach for the pill rather than a learned tool of self-regulation. Mhm.

This is I mean we I don't know how much you use hypnosis, but I I've worked with a hypnotherapist who does a lot of self-hypnosis training for patients in this exact situation. So yeah, they they feel a pain swelling and rather than panicking and spiraling the response and engaging the sympathetic fight orflight, they

self hypnos.

Yeah.

And they're able to just take the air out of that flare. Amazing. Amazing. Yeah. Hypnosis is an amazing dream when people don't already know it.

So, I I appreciate you for sharing this because the having those tools available, knowing that they exist, knowing that there's internal things that patients can do that they can learn and it's a it's a muscle they have to learn it, they have to train it. It doesn't just come naturally, right? It takes a bit of practice,

but then to have some control over their body, they they could start to get some sense of agency again.

Yes, absolutely. And and I think the pill point that you're making is complicated for the exact reason you said, which is that we actually prescribe a lot of pills. You do and I do both. And sometimes I, you know, I'm thinking of a different patient we shared where um they really needed help to be able to even slow their mind down enough

to try to use these tools. Um but that was a short-term thing. So we used uh an as needed anxiety medicine to help reduce because when the pain came they were in like basically a panic

and when you're in a panic the idea that you're going to just all of a sudden use all these wonderful tools it's kind of hard for most people. So what we did is for a short period of time we helped dampen the panic so that they could slow down and then they could practice these skills and then they kind of build the muscle and they get better at it and now she doesn't use that medicine anymore. But sometimes we have to do that to bridge people because by the time they've come to me um and you I think often things are are are quite severe.

So we're not in the sort of nipping in the bud sort of part of things and and so um we have to be creative.

Yeah. No, absolutely. Medications are a mean to an end. A means to an end.

Uh one thing we talk about here is psychological sensitization. So when we think about sensitization, we kind of group it in three categories. There's neurologic sensitization which happens when the sympathetic nervous system is hyperactive. when there's some physiologic neuropathic process that upregulates pain signaling to the brain. Uh we think about inflammatory sensitization when the tissue actually becomes sensitized because of the inflammation with autoimmune mass activation syndrome those kinds of things. And then the psychological sensitization and the psychological sensitization like the most obvious is is the patient who cannot cope who you know panics with the smallest reminder of the pain.

And there's there's a lot around that. We can dig into all of that. But then we also see the opposite where patients dissociate from their body

where they almost have a learned disregard for that painful area of the body. And I've even seen patients that don't even acknowledge the pain and I can examine them and I can reproduce it and I can find the pain but it's not something they came in and complained of even though it is very central to their underlying medical issues. uh can you talk about maybe psychological sensitization as a topic and how you approach it?

Yeah, I mean I think you guys are so sophisticated in your way of thinking about the nervous system and how how people are sort of managing these things. Um you know I think you're right there are some people who sort of dissociate. Um I probably my experience is more of the person who essentially to you know for lack of a better sort of freaks out and that can be um sort of caught up in a whole bunch of different stuff right one can be just yeah like you said before you know the sympathetic nervous system is in overdrive they start to panic um but there's other kind of more subtle things that are going on sometimes so um you know a patient has pain before an important family event now they feel they're in a pickle do I go and I went and people know I'm in pain or do I just cancel and avoid and then nobody has to see me unwell.

Um, and I see this a lot and this is how people with pain end up really kind of this mix between homebound and agorophobic. And the reason I say it's a mix is because um, yes, they're in pain. It is hard for them to leave the house. But in my experience that often it is compounded by the fact that they don't want to be seen in this way. Um, and there's a lot of shame around how one has to present in order to be out in this world.

But the more you stay home and it's a very self-reinforcing thing. Um, so we always say avoidance behaviors are anxiety behavior. So it's essentially saying I'm anxious to be out in this way. Um, so I'm going to just hold up. But ultimately over time it shrinks and shrinks and shrinks your life. Um, and so one of our big challenges is helping people to understand that it's okay to be out in the world and sort of not be as well as you once were and how can we kind of learn to tolerate that and get the people in your life to tolerate that.

Often the people can, but they don't imagine that people will be able to um tolerate it. There's an identity shift. Yeah. And there's some self-acceptance around that identity shift. And then that identity shift is not a permanent state or at least that's the hope,

right? So it's it how do how do patients cope with shifting shifting identities thinking of themselves as a pain person accepting somebody with pain and then at the same time hoping to not be that person anymore.

Absolutely. And you're right, you do have to hold this duality, which is to say, I don't want you to feel like this forever, but while you feel like this, what are we going to do to help give you a meaning, like as much meaning in your life as we can? And that's one of the things I really work with. And one of the reasons that our practice works in this way is, you know, for all of the folks we've shared and for any of my folks with chronic pain, I'm speaking to um you the pain doctor, but also the, you know, usually there's some other medical specialty doctor, the orthopedic doctor or the GI or the surgeon or whomever.

And I'm also almost always speaking to the spouse or partner

because sometimes the person has an imagination of what that partner is expecting out of them. And it's often um not totally accurate. And when you talk to everybody and get everybody on the same page, you can really help um the person understand um what we're doing about this so that you can feel better, but also what can we do in the meantime to to kind of give you as much life as you can.

Yeah. If if we go back to the sensitization, one construct that I use is the emotional bladder. Uhhuh. Uhhuh.

I I I feel like we all have an emotional bladder where we can tolerate a certain amount.

Yeah.

And then we have to empty our bladder.

Yes.

And and even for the patients who dissociate, there's a there's a level of fullness that gets in their bladder and then it doesn't take much. It could be a missed train. It could be uh a stubbed toe. Something completely unrelated to the primary pain, but it spills them over. their emotional bladder fills up and they get pissed off.

Yes. Yes. Irritability huge thing for folks with chronic pain or to your point um a stub toe. What what I like about the analogy is sometimes you'll find there's some other medical problem too.

Yeah.

You know that's actually quite problematic that still has to do with um how you have the sympathetic overdrive and um carrying so much tension, anxiety in the body. Um it will come out in other ways. uh constipation or diarrhea, you know, all these other like sort of IBS type things. So, you'll see, you know, our body um can only hold in so much stress and um emotional the phrase we from the bladder is emotional reserve.

Yes.

Um but you're totally right. We all have only so much and we have to find ways to metabolize these emotions and one really um really healthy way is to talk through it and sometimes people do that on their own and with their own families. Um, but I think often having someone who hasn't been a part of this whole journey can be really really liberating for them. Can I ask for the talking through it part? I mean, a lot of the patients I work with, they've talked through it and they talk to it till they're blue in the face,

right? And and I understand with trauma, there's this process of telling the story until you get bored of it. Yeah. Yeah. But all all of the patients with pain, they've told their story so many times, they're bored of it, but the pain hasn't gone away.

Yeah. What do you do then? Yeah. Um I think that that's one of the challenges is a holding with them the hope of getting better and then you know there's a phrase um sort of a type of psychotherapy we call acceptance and commitment therapy where you essentially you're saying um it's okay to hope you have a a cure or something gets meaningfully better in the pain. But in the meantime I'm going to accept the fact that I'm a person with this problem and that have other goals and and desires in life.

and how can I sort of start to do that? Um, and and start to work towards those things.

And so, you're right. I don't you there are a lot of therapists out there who just sit and stare at patients and let them just talk for 45 minutes. And that's not my style at all. I think you have to start nudging and moving people towards a direction of moving forward. The nice thing is moving forward means very different things to very different people. So, it's moving forward a way that has some meaning to them. Um, you know, I've had people who they couldn't travel.

So, one of our big goals was to start to get them to figure out how they could travel. You know, well, maybe we book refundable trips. Maybe we only book a plane ticket times that work for you. Maybe it's really short. Maybe we start driving um before and we work our way up. Um but we have to find something that's meaningful to you and start working towards it.

I love that these are all very concrete goals.

Yeah, they're they're not emotional goals. They're actually physical concrete life engagement goals. which really refocuses I mean if there is a panic response if there is a proveration it really refocuses to a very physical concrete goal which seems like it'd be very helpful.

Yes, I think so. I I think you're right. You know there's such a balance. Of course I'm working all day every day in the world of emotions. I want to hear how things make people feel. I do ask that question. How does that make you feel? I do say that. But we can't only ask how does that make you feel. We need to understand um where we're going to go with it. Where are we going to go with these feelings?

Right?

Which ones are useful? Which ones are not?

Right?

And then and then we're going to start say like what is our goal? And then when we tried to do something like how did you feel about that? How did it go? Like what went well? What didn't go well? And then we can keep navigating. But implicit in that whole process is that we're going to keep moving forward. We're not going to stay here.

That's perfect. Can we speak a little bit about the gaslighting that happens especially in pain? I don't know how much it happens in psychiatry on its own. I'd be curious if it does, but you know, we certainly meet a lot of patients that have seen plenty of doctors who told them their pain wasn't real or it's in their head or,

you know, basically the the other providers pick up on the the psychological sensitization piece, which you know, patients desperate for care will of course naturally amplify to get attention to be heard because they're so often not heard. But then that's interpreted as a psychological distress signal and not an actual physical pain signal. How do you help patients acknowledge the trauma that they've been through, distinguish that from the actual pain psychology and and cope and process all of that and and feel safe at the same time?

Yeah, it's a really tough one because um I'm thinking of another patient that you and I shared where had a very long medical journey and even when he came to me in part implicit in the consultation was sort of a question you know by the family of you know is this in his head in in part because certain parts of pray pain reprocessing therapy were helpful. So it's kind of interesting people to your point they notice yes there's a psychological component to this and it begs the question to um the family sometimes or to doctors who have tried six things that didn't work um is it all then you know they kind of take it a little bit to an extreme is it all in the head is it all psychological and emotional and um I think it can be you know I'm thinking of of this shared patient and um he came to you and you injected lidocaine into one specific nerve and he felt immediate get, you know, 98% reduction in his pain from like horrible to nothing.

And as he told me and recounted that story to me, he cried because it was such a validation that all these other people who had kind of, you know, people can can feel when there's kind of a side eye or a second thought, you know, whether doctors actually said it to his face or not, he could feel that there was a doubt.

Yeah.

About the veracity of his pain. And I think to have that validation that there was this organic thing happening to him was tremendous for him psychologically. Yeah. I mean it's essential. Part of the challenge is when when there is elevation of the sympathetic nervous system, when there is a chronic pain state, there is an elevated experience of the emotional part of pain. Yeah. and and acknowledging that and understanding it uh and knowing how to deal with that as a patient and distinguish it is all part of the work we both do.

uh the the part of the medical trauma sometimes that comes in so strong that it's hard for a patient to build trust to build rapport of course

to you know a lot of patients have lost hope or not necessarily lost hope they've they're too afraid to hope because they've hoped before and hope has failed them. Mhm.

How do you how do you engage with a patient who really has they they have no hope to give you? They're there and and I see this a lot. A lot of patients come in with this chronic pain state. Deep down they want it to go away, of course, but they have no hope to spare. If I can help them, great. But if I can't, they're ready to be disappointed.

Yeah. How do you how do you begin engaging with patients in that state?

It's tough. You know, hope I I always say in in my work, hopelessness is a delusion. It's a it's a trick that your mind is playing on you. Um you know or a wise person once told me where there is life there is hope. So um what does that mean? Um it it means we have to keep kind of um persevering and and moving along and and yes some people with um severe chronic pain and I'm sure um you've seen it in your practice but um some people do become suicidal um and it is an existential crisis and they do think about it in their lives um or say things like I I I won't continue to lose weight or if this lasts a certain amount of time and part of our job there is to talk to them very frankly and honestly about what we're going to do um to of course keep them safe to give them enough chance to avail themselves of treatments.

And one of the problems with hopelessness, and the reason I say it's a delusion is because it becomes really problematic because whether they're working with you or with me, they do need to spend some time to see the thing through. And I think for folks, to your point, with all this medical trauma, they've seen all these um doctors and clinics,

maybe sometimes they've been misdiagnosed or undiagnosed,

but I also think there are times when folks have trouble because they're so hopeless, because they're so despondent. you know, they they kind of try something but only very briefly. Yeah. And they we we kind of need them to see the whole thing through. And um that's hard. And I I kind of I sympathize with their situation and part of my job is to challenge them and say like if we're going to try this, we need to give it, you know, and that would be where I collaborate with the other physicians, with you and the and the other specialists to say like how long before we should expect a response.

How how long do they need to keep, you know, giving this an honest try? That's that's one of the challenges with complex chronic pain. like if if it were just one thing, somebody would have found it and fixed it and they wouldn't be in this situation. It's usually the culmination of several factors built up over time. They may not have noticed all of these things building it. They may have been in the background until there's the straw that broke the camel's back, but there there's usually more than one thing going on.

And to reverse all of that, especially when it's been going on for a long time, I mean, mechanically, physically, like with what I do, it's work. It's a process. I

I I almost never have one single shot or medication or procedure that will undo and set them back on the life that they had 5 years ago.

Yeah.

You know, even if we can get the pain to go away now, there's still a lot of rehabilitation to get the body working the way that they want it to be. Like there's always a process to it. And that process is also always iterative.

Yeah.

Like we never know every step that's going to be required to get them better. Yeah. And it's like untying a knot. You see which thread to pull on first, but you don't know what thread you're going to need to pull on next.

That's right.

And and this is a big knot. There's a lot of threads to pull. And having the patient who has no hope to share uh engage on that journey, it's a lift. It's a big ask. And I I don't blame them at all because I I understand where they're coming from.

Yeah. And I think if the hopelessness is really profound um this would be another indication for considering um ketamine as a piece of the treatment.

Can you tell me more about that?

Yeah, I mean uh I ketamine and sabbato by the way as well um have been shown in study after study to rapidly improve depressive symptoms including hopelessness and um suicidal ideiation in in patients. Um that's just with depression, suicidal ideiation all by themselves. But you can imagine and I and I know you guys do it here. Um, ketamine is also an anesthetic and also works for pain. And so for folks with this kind of both of these problems together, I think it's a nice opportunity to try to give them a little bit of a reset so that they can have some perspective and and it it generates some internal hope because we know that positive expectancy absolutely changes the outcomes of treatments.

So, um, the example I always give people is, um, people think they understand the placebo effect, um, and and they talk about a lot in in mental health pain, but I like to talk about it in a totally different category, which is if you put people on a a randomized control trial with blood pressure medication and placebo. What's interesting is not that blood pressure medications drop your blood pressure and heart rate. What's interesting is that the placebo, the sugar pill, drops your blood pressure and heart rate.

Why? because of positive expectancy because you believe that there was a chance that your blood pressure, heart rates are that shows you how powerful our minds are. It's unbelievable. These people with sugar pills are dropping their blood pressure.

Well, this is why people seek out gurus as well.

Yeah, absolutely.

I have patients that will travel the world to go see guru for this or guru for that because they believe there's an expectancy that they can be the magic healer.

Right. And I think our balancing act as western medicine doctors is really instilling hope. I think it's so important um and instilling positive expectancy. But yes, it has to be couched in science and it has to be reality based. Um so we're not selling steak oil or anything like that. But if people can't engender any hope inside of themselves, um then I think it's a it's a great opportunity to get ketamine. What we've seen is that ketamine promotes neurogenesis.

So you've got sprouting of nerves um and um really activating neuroplasticity so that the brain can see things differently. I think that can really help people open their minds to keep trying. Um whether that be that ketamine is the whole treatment or whether I more commonly it's a piece of a of a bigger puzzle parts of the treatment.

And and what you're describing I I've seen it both physically and psychologically. I I've had patients with physical pain come out of a ketamine session with their posture adjusted, moving in a way that they hadn't in 20 years and recognizing that, hey, their body can still do this.

Yeah. And that just like you mentioned with the local anesthetic block and the other patient, that reminder to the brain of what normal feels like, it it's kind of a north star.

Yes.

It it it gives them something to anchor on or to align to that reassures them that it is possible. Yeah. To to reach achieve that. Absolutely. And the the same thing psychologically it it's the way I I mean my non- psychiatrist brain the way I think of emotional processing is almost like there's a pipe but that pipe gets clogged. And because the emotions can't get through the pipe they back up and they overflow. And when those emotions overflow, that causes a lot of the overwhelm.

That causes a lot of the depression or the dissociation or the avoidance of all of those feelings because they can't process them all at once. And and of course, that also helps amplify the pain. Y

because the pain is often easier for the brain to accept than the emotional overwhelm.

Yeah.

And we can also go back on this and talk about that's part of that sensitization process. But anyway, thinking about this pipeline for emotions needing to be cleared, the the ketamine can be tremendously helpful for that patient to recognize what's blocking their pipe.

And it may be something completely unrelated to the pain. It may be something from their childhood. It may be something that happened at work. It may be something that I don't know that they just hadn't processed, but it was substantial enough that it kept them from being able to process everything else that came up. Yeah, absolutely. I mean, the ketamine um I think has been a real game changer um in psychiatry especially because it works quickly and I think there's so many treatments in our field that you know take a lot of time and patience and and sometimes people don't have the patience anymore and so we need to give them something to kind of jumpstart the treatment even if we're going to try some of the longer acting pills that do take longer as well.

Um, I think it's a nice way to offer help early and my approach to pain is really twofold. In the treatment phase, it's really twofold. One is getting the patient comfortable.

Yeah. Because you don't go to a pain doctor if you don't want to be comfortable. And the other is figuring out what's going on, right? Like what what are the diagnoses? How do they come to happen? Why are they happening? Why are they not getting better? That's the work that I have to do. People don't usually think of a pain doctor as being the that, you know, the three-level diagnostician, but I'm really the one in the position to figure out mechanically with their body what went wrong and why it's not getting better.

And that's ultimately what I have to fix if we want the pain to go away. So, yeah, when when we need to get them comfortable urgently, ketamine is fantastic for that. IV lidocaine, you know, lots of oral medications that we both use. Uh can we speak a little bit about uh psychiatry and the role of psychiatry, pain psychology, the role of pain psychology and then regular talk therapists which might be psychologists, they might be social workers. How do you describe the landscape of care in psychology that's available for patients?

Uh for patients specifically with pain, I think what

Yes. Yes. Um well I think it's tricky because like I said I think people with chronic pain um presenting and you're right our field we have psychiatrists who are medical doctors and then psychologists uh who are PhD or sides and then licensed clinical social workers and others and they all have their role in sort of a mental health ecosystem. I do think one challenge with folks with chronic pain is um if you're finding a therapist only either finding somebody who has experience with pain or experience working in medical type settings because what you don't want is to go and see a very lovely compassionate therapist who just says oof.

I'm sorry that sounds like a lot. Did you talk to your doctor about it? You really want a therapist who's going to get involved and engage in the pain component of things. That might mean that they have to call you or the other specialists, but um they don't need to be medical doctors themselves. I'm certainly um not trying to redo the specialist treatment of my patients, but I do want to make sure that um they understand that I understand medically what we think is going on.

Um so that's one piece. And I think the second piece for for folks when you're looking for therapists is um you know there's a lot of what um in ultra president was called fern and lamb psychiatry and psy psychotherapy in America. I think yes it is a part of our job to listen to our patients and they should be talking more than us and in general that's the truth. Um but I also think that if therapist is just staring at you waiting for you to figure it out for yourself I don't think that's very helpful for folks with chronic pain.

I think they need a little bit more of a guide um who can help them along the journey. Um so it's important to be listened to but I would say that's necessary but probably insufficient for a successful treatment um when when folks have chronic pain and um some type of mental health component to it.

A lot of psychiatrists just do medication management. How do you balance the psychotherapy and the medication management piece? Uh

yeah, I think medication can be enormously helpful to folks with chronic pain. Um, you know, like I said, there's um, duloxine or symbol, which is FDA approved both for pain and for anxiety, but there are other medications we can do to help dial down that sympathetic nervous system and really improve people. Ketamine has um, uh, dual FDA approvals for depression, suicidalation, and for pain. Um, so there's definitely, I mean, I always remind there's only one brain, right? We only have one brain.

It's not very surprising to me that a lot of our medications overlap. Um, and I think getting a psychiatrist to prescribe medications alone in this context will again not really work. Um, because there's too much to figure out. There's a lot to hear. You got to really understand their story and like you said, the medical trauma. Um, and also you've got to understand medically what's going on from the perspective of the other specialists and from their loved ones. um in my experience spending the time and like work to get all that information it's um a lot but the patient ultimately really really benefits from it and and really likes it.

So um you know I think psychiatrists can play a really wonderful role on the pain journey but we have to put on our psychotherapy hats too and really um you know listen and and sort of help the person talk through how they're going to move forward. M what advice do you have for patients who are looking for a psychiatrist?

Um yeah, great question. I think if you're looking for a psychiatrist, you want to find somebody who is going to have the time to spend with you. Um so if they say their follow-ups are 15 minutes or or something like that, that's definitely not going to be enough. Um who do longer evaluations? Um it's nice you you can look for people who have training in psychosmatic medicine or console leases on psychiatry. I don't think that's a requirement, but it is a nice to have.

Um, but but really folks who've had experience, I think, with with dealing with these kinds of folks and have an interest in it. I I think if we're really honest, in every specialty, people have their preferences. And I think you want a psychiatrist who wants to lean in with you.

Um, and sometimes you can find that out on a 15-minute call or you can even just, you know, check in. Um, ultimately I always I believe patients are consumers. I think they should get the best doctors they can get. And so it's I would say it's okay if you want to try out a couple people um to kind of feel like you're really feeling heard and you feel comfort.

Well, and also more sets of eyes are helpful. Yeah.

I mean I I never steer away from having patients get second or third opinions because they may pick up on something that I miss. I've seen patients who have been through these before and it's I I call it conversion therapy for pain because it really is like that. uh the pain is very much real and they try to talk themselves out of it and they end up just building up all this self-doubt uh and and then of course there's all this anger and all this resentment and the self-doubt doesn't go away like it it's almost ingrained from that experience even though consciously they know that that was all bologoney.

Uh how do how do we protect patients from things like this? Yeah, I think you know patients um understandably are desperate and they're they want to go wherever they can you know feel like they can find results. Um but of course it's immediately alarming to me when when one doctor saying you can't be pursuing X Y or Z simultaneously. I think part of our role as as as physicians particularly working in the intersection of um pain um mental health emotions is we have to appreciate the brain is the last frontier of medicine and we know a lot about cancer and we know a lot about the heart we know the least about the brain and I think if you don't approach this area and these patients with enormous amount of humility um I think that's deeply problematic uh from job the truth is we don't know exactly what you know any given patient is experiencing in their in their bodies and minds at any moment and our jobs to try our best to understand and help best we can.

I think people who are proitizing are saying um that they kind of know it all. Um I think that's immediately a red flag.

Yeah. I mean I I very much tell patients that you know pain is a journey and we might think we know what's wrong with you but we don't actually know that we know until it's better and then we can look back and say oh that was it.

Yeah. Exactly right. So like I because the pain has so many layers to it. We may recognize the most superficial layer. We may treat that superficial layer, but if it's not the root cause, it's not going to stick. That pain's going to come back. Yeah.

So until a patient finds long-term relief that like is a proven durable solution, only then can we say this is what was happening. This is why it was happening. This is how it came to happen. This is why it wasn't getting better on its own. Only only after it's fixed do we really truly understand what it was.

Uh how can patients find you? So you can go to our website www.archcschychiatry.org. I'm an elite psychiatrist and we have a couple other psychiatrists who are extremely well trained and and thoughtful as well.

Fantastic. Well, I really appreciate you joining us. This has been a great conversation.

Yeah, likewise. Thank you. You're very welcome.

Thank you for joining us on another episode of Care Beyond the Pain. The pain journey is rarely a straight line. To learn more about how to navigate it, you may visit our website, manhattanpain medicine.com, or read our book, Pain Answered, found on Amazon. Until next time.