Day 18: Conditioned Responses In the late 1960s, comedian Steve Martin was on top of the world. His career was taking off, he was making good money, and he was dating up a storm. But then one night, it all came crashing down. He was out with his friends, when out of nowhere he had a crippling panic attack. “My heart began to race above two hundred beats per minute,” he said. “The saliva drained from my mouth so completely that I could not move my tongue.” The next day he was feeling better, but that very evening, he had another panic attack! His brain had developed an unfortunate connection - he came to associate nighttime with anxiety. And this association lasted for months. During the days he was fine, but as soon as the sun would set, he was a mess. Steve Martin developed a conditioned response - his brain connected a physical symptom with a neutral stimulus. Conditioned responses are very common with people in pain as well. This occurs when pain becomes linked with a physical position or activity. For example: Sitting Back pain Typing Wrist pain Eating Stomach pain But in the case of neural pathway pain, it isn’t the position or activity that’s causing the pain, rather it’s the belief that the position or activity is dangerous that’s causing the pain. Learned Behavior Evolutionarily speaking, conditioned responses are actually helpful. If you eat a poisonous berry and get sick, you brain creates an association. It puts a “DANGER” sign up, and after that, even the smell of that berry can make you nauseous. Conditioned responses can protects us from repeating dangerous behaviors. But what if that berry wasn’t poisonous? What if you just happened to get sick shortly after eating it? Your brain – not taking any chances – might create an association anyway, and put a “DANGER” sign up on a food that’s actually safe. Assuming you have neural pathway pain, this is how conditioned responses develop. Your brain interprets a safe behavior (sitting, walking, typing, etc.) as if it’s dangerous. In the following clip, a 17-year-old named Mya developed a conditioned response to eating. Her brain learned that food = danger, and it’s responding accordingly. Thankfully, Mya’s currently working with a specialist to help her unlearn this association. Unlearning What We’ve Learned The way to overcome conditioned responses is to teach your brain that the position or activity it's interpreting as dangerous, is actually safe. The first step in this process is acknowledging the obstacles. Often we're able to accept intellectually that we have neural pathway pain, but on a gut level we still have a tendency to think physically. And this makes sense. If you sit and you have pain, or you walk and you have pain, it’s a logical conclusion to think that it’s the sitting or the walking that’s causing your pain. Everything you've ever learned about cause and effect is telling you that's what it is. So to overcome conditioned responses, we actually have to embrace a perspective that's inherently counterintuitive: “It isn’t the sitting that’s causing me pain even though it hurts every time I sit?” Searching for Exceptions It’s hard to embrace a reality where our senses are essentially lying to us. Gathering evidence to support this perspective can make it lot easier. The most compelling evidence that there’s nothing physically wrong with us comes in the form of exceptions. The Exception By 2006, I’d been suffering from chronic back pain for several years. It was pretty consistent – the longer I sat, the worse the pain was. Even though it hurt to sit, I tried not to let that stop me from living my life, and in April of that year, I went to a Lakers-Suns playoff game. In the fourth quarter of the game, the Lakers made a huge comeback, and Kobe Bryant made a last second shot to push it into overtime. Overtime was even more exciting, and he made another last second shot to win the game! It was pandemonium! But nobody in the stadium was more excited than me, because for the first time in two years, I was sitting without pain. Sometimes when we’re deeply distracted, we’re unconsciously depriving our pain of its one fuel source: fear. When this happens, we can develop exceptions – instances where the pain isn’t what we would expect it to be, given our physical position or activity. Finding exceptions can help us more easily believe that it isn’t the position or activity that’s causing our pain. While finding these past exceptions can be helpful, if you don’t have any of these instances, it’s okay. As you continue teaching your brain that it’s safe, you increase your likelihood of getting these exceptions. Compiling the Evidence There are other ways to gather evidence that your pain isn’t physically caused as well. Have physicians been unable to find any cause for you pain? Did the symptoms come on without any preceding physical trauma? Does the pain seem to ebb and flow based on your stress level? None of these are definitive proof, but we’re trying to build a case. As you continue to gather evidence, it’s a good idea to put together an evidence sheet: a list of all the reasons to support that your pain is psychogenic. One of our former patients has offered her evidence sheet for us to share: Reinforcing the Evidence The night of my magical Lakers experience, I remember thinking, “It’s psychogenic for sure! I’m free!” Then the next night I was out to dinner and my back started hurting, and all that went out the window. No matter how much evidence we have that our pain is psychogenic, it can be hard to hold on to that when we’re in a pain state. It can help to reinforce the evidence that you’ve gathered throughout the day, especially when you’re in a pain state. “Right now, I’m thinking it hurts because I’m sitting, but because of this piece of evidence and that piece of evidence, I know that it isn’t the sitting that’s causing the pain, it’s the belief that sitting is dangerous that’s causing the pain.” The more you’re able to internalize this message, the more likely you are to gather even more evidence. It can become a positive feedback loop. Ultimately, when you’re able to teach your brain that these physical sensations are non-dangerous, the pain begins to fade.