PreFrontal Nudity

The brain exposed

Embracing Pain

The difference between pain and suffering
Alex Korb
This post is a response to Yoga: Changing The Brain's Stressful Habits by Alex Korb, Ph.D.

In college I played on a highly competitive Ultimate Frisbee team (I know this is a somewhat humorous blog, but that’s not a joke). I’m not here to debate the relative merits of Ultimate Frisbee as a sport; you just need to know that we were one of the best teams in the country, and that we trained hard. In addition to intense practices we did plyometric exercises, lifted weights, and ran track workouts. Long story short, in my senior year, during a particularly difficult track workout, I learned something about the way the brain processes pain that has stuck with me ever since. In fact, it’s something I strive for.

I had a great time my senior year of college, but it wasn’t always an easy time. Some of it was the usual college stuff: I didn’t have a job lined up; I didn’t know what I was going to do with my life; and all my friends were about to scatter across the country. But on top of that my girlfriend broke up with me; I was skirting the edge of depression; and for a few weeks I had a tooth infection that hurt so bad I had to get a root canal. Tooth pain is terrible, because not only does it hurt to eat or drink cold water, but it also wakes you up in the middle of the night and demands your full attention, seeming to envelop your whole world. You’re left aching in the dark wondering what the point of anything is … and you’re alone.

But I was fortunate enough to play ultimate. I was never a particularly good athlete in high school, even though I tried really hard at a lot of sports, but somehow I just took to ultimate and it felt like a dream come true.On top of that ultimate offered something with a clear goal. I might not know what I was doing with my life, but I could sure chase after a frisbee. I might be lonely in my painful nights, but during track workouts the team would all suffer together. Ultimate was straightforward, challenging and meaningful, with great friends to enjoy it with. I realized only later that those opportunities in life come few and far between.

Since our season began in the bitter cold of a New England January, we ran our brutal workouts at an indoor track, with warm, rubbery air, and lights the color of I Can’t Believe It’s Not Butter. To build both speed and endurance we would run sprint after sprint after sprint, with only short breaks in between. The hardest sprints were the long ones: 400 meters, a quarter of a mile. Almost anyone who runs track will tell you that 400s are the worst. I would agree. Sprinting 400 meters means subjecting yourself to over a minute of burning muscles, aching lungs and a pounding heart. For shorter sprints, like 100s or 200s, you can just power through the pain without thinking much about it. But with 400s your muscles and lungs start screaming like a carful of spoiled children asking “Are we there yet?” and you’re still only halfway done. To top it off, when you stop running, your stomach usually begins to squirm. By the time you’re just recovering from the last one – or not recovered at all – it’s time to go again … and again.

Fortunately as the season progressed we would do fewer 400s, and replace them with more 100s and 200s. And then in late March, just before the playoffs started, the captains announced, “Today is the last set of 400s.” I was very excited.

Because it was the last of the 400s, I tried to push myself even harder, although that didn’t have much of an effect other than to make me feel queasier than usual. When it came time to do that very last 400 I was gassed. My heart kept racing during the rest period. I dripped sweat, and my stomach churned as the room seemed to gently wobble. My legs trembled.

As we started the last one I dreaded the ensuing discomfort. My legs felt thick and slow, and I just couldn’t seem to get enough oxygen. I was trying as hard as I could, but my muscles just wouldn’t respond with more speed. My calves burned, my thighs burned, my lungs burned.

As I neared the halfway point, I had a similar thought to what I always did, something like “Ugghhhhhhhh” followed by some inspirational self-talk like “gotta keep going”. And then something remarkable happened. As I rounded the turn, I began to recognize that this was the homestretch of the last 400 of the season. And since I would be graduating in a few months, it was my last season of college ultimate, and another thought popped into my head: “This is the last 400 I will ever have to run in my life.”

The thought washed over me, releasing a mixture of excitement, sadness and nostalgia – excitement that that particular type of torture would soon be over forever, a sadness that all that meaning that ultimate provided would disappear, combined with a nostaliga for my college years that even somehow included the present moment. There was also gratitude for being able to compete at such a high level, something I never would have thought in high school I would be able to do. There was more gratitude for the teammates who were also friends who were pushing themselves in pursuit of the same goal. And as the wave of thoughts and emotions washed over me, all of the pain in my body vanished. 

The aching disappeared. The burning subsided. And perhaps most importantly, a feeling of peace settled on me. Now, I couldn’t necessarily run faster. I could still feel the muscles notifying me of their struggle, resisting my efforts to move them quicker. But I wasn’t worried about it. I was comforted by the fact that I was trying as hard as I could. It had some aspects of an out-of-body experience, but in fact was the opposite; it was a fully embodied experience. I became aware of how my skin felt sliding over my muscles as they contracted and relaxed, in a way that you’re either usually unaware of or too distracted by the pain to notice. I could feel the sweat dripping down my face and evaporating coolly into the thick air.

Pain Signaling vs Pain Perception

The signaling of pain is a fairly simple system. There are pain neurons throughout the body called nociceptors, which send out pain signals whenever they sense bodily harm. Some nociceptors have sensors for skin damage or extreme heat or cold, others for muscles being stretched too far or working too hard. For example, if you get a cut on your finger a nociceptor sends a signal that travels up the spine, gets relayed in the thalamus, and zooms up to the cortex where it enters your awareness and you say “ouch”. Or sometimes it can be the icy sting of cold water stabbing at a sensitive tooth.

But while the signaling of pain is pretty straightforward, the perception of pain is a strange beast – fluid and dynamic. Sometimes the nociceptors might send a tiny jolt and it makes you cry like a baby, and other times they might be blazing all over your body and you hardly notice it at all.

Pain is a very particular type of sensation, because it almost always has an emotional component. We don’t just perceive pain objectively: “Oh, my hand seems to be stuck in the car door.” We have an automatic emotional response to it, “Mother fudger! Cheese and crackers!” It gets our autonomic nervous system, specifically the fight or flight response, all fired up.

Therein lies the difference between pain signaling and pain perception. Pain signaling is simply a sensation that zips through your nociceptors and up to your brain. But when it comes to pain perception, we most often experience it not as just another of many sensations, but as suffering. Suffering is the interpretation of that pain sensation, often automatically imbuing it with negative emotions. It is, in fact, this suffering aspect that we most want to avoid. It can make you uncomfortable, unhappy or downright depressed. It can even sap your willpower and motivation.

But the story gets even more complex. Not only does pain perception influence your emotions and motivation, but it can also be influenced by them. For example, one study at Oklahoma State (Carter et al, 2002) used the power of suggestion to induce subjects with various emotional states like depression, anxiety and elation. The researchers then tested their perception of pain by pushing a dull blade into their knuckles. The researchers showed that when subjects were made to feel anxious or depressed, their pain tolerance dropped. That is they experienced more pain from the same stimulus than the “elation” or control group. Despite the fact that their nociceptors were sending out the same signal, their brains translated this signal into more suffering.

Other studies show that subjects are willing to endure more pain when they’re motivated by money (Van Damme et al 2012) (No, not Jean-Claude). This may not be surprising, but shows how pain perception can be influenced by whether or not we have a reason to endure the pain.

Pain perception can be modulated by your emotions and your motivations because your prefrontal cortex and emotional limbic system can exert “top-down control” over the pain signals coming up from the body. Basically, depending on what’s going on in your mind, your prefrontal and limbic cortices can signal a region of the brainstem called the peri-aqueductal gray (PAG) to release it’s own type of morphine. You’ve probably heard of it. It’s called endorphin, which stands for “endogenous morphine”. Endorphins work the same way as other narcotics like vicodin, or Percocet or even heroin (I’m told). Narcotics don’t alter pain signaling per se, they just alter the pain experience. They get rid of the emotional part. They don’t necessarily eliminate the pain; they just make you not care about it.

What I learned

On that last 400 the thoughts and feelings swirling around in my head activated the PAG, and the rush of endorphins silenced the emotional part of my pain perception. The mechanism for this I learned in a classroom, and from textbooks with detailed descriptions and illustrations of what brain regions project to where, but it is not the deepest lesson I learned from my last 400.

What I really learned from that last 400 is how suffering is inextricably linked with meaning. It is not the pain itself that causes suffering, but the meaning behind it. You suffer from pain not just because of how it feels, but because of what it means. In some sense all physical pain is really just emotional pain that is triggered by a physical stimulus.

Before my root canal, when I lay there in my solitary nights, awoken at 3AM by a pounding ache in my jaw, the pain meant loneliness, heartbreak and fear that all of it would just continue forever. My future of pain and solitude was inescapable. And of top of that I had no reason to endure it. All the pain was just a pointless journey. These less-than-inspiring thoughts left me wallowing in my suffering.

Similarly, at the start of that last 400 my mind was still stuck on everything that was going wrong, how tired I was, how much I didn’t want to be running a 400, how I just wanted to give up. The pain meant weakness; the season ending and the guidance it had provided; the joy of college ending; that the best years of my life were passing too quickly. So when all the pain signals started coming from my muscles, of course my brain translated them into suffering.

And then one thought changed everything. One thought turned that last 400 from an arduous struggle to a nostalgic victory lap. After that thought the pain meant I was pushing myself to become the best athlete I could, and to be a good teammate. The pain meant more than just pain. It meant my life had purpose and direction. The pain meant that I was living fully, pushing myself to my limits, being the person I wanted to be. It also meant I had a team of friends who were all willing to endure that same pain for me. It meant that even after college I could still pursue lofty goals and have the fortitude to reach them.

The start of my last 400 and the end of it both involved the same physical actions, but what I was doing was reframed in a new perspective. My reaction to the pain, even to the thought of pain, changed dramatically. Pain often causes us to dissociate from the present moment, to wish we were doing something else, experiencing something else. But pain only becomes suffering when we resist being in the present moment. When we embrace the present the pain becomes something else entirely.

Embracing the present, even for all the pain it may possess, is one of the central tenets of yoga. It’s also right there in the bible. I am not a religious person, but there is a certain bible passage that I read in high school that has always stuck with me, “Let us rejoice in our suffering, knowing that suffering produces endurance, endurance produces character, character produces hope, and hope does not disappoint us.” (Romans 3:3-5).

I always used to think that avoidance of pain was a fairly universal guiding principle of human behavior. But then I came to understand that it’s not so much that we wish to avoid pain, just that we want our pain to be in the service of some greater purpose. We want it to be meaningful. We want it to be worthwhile.

So when faced with some unavoidable pain in my life I try not to think about eliminating it. Trying to eliminate something that is unavoidable is an exercise in futility. The pain will still be the same, but your suffering will be greater. I try to remember that it is not the pain that bothers me so much as what it represents. I try to place the pain in the context of what I’m trying to achieve. I try to make it more meaningful.

With my tooth pain I don’t think there’s anything I could have said to myself at 3AM, waiting for the advil to kick in, to eliminate my pain entirely. I was searching for love, and hadn’t found it. I was leaving my friends behind. I didn’t have a career path. And while all these things were true, wallowing in them made the pain worse. But just because I couldn’t necessarily eliminate it, doesn’t mean there was nothing I could do. To reduce my suffering I could have reminded myself that all this was temporary, and that there were many wonderful women still out there, that I could still stay in touch with my friends after college and also make new ones, that the world was full of endless possibility.

Pain is just a signal. It is a test to see if your intentions are true. What does your pain mean to you? What are you doing with your life that your pain is not worth enduring?

The funny thing is that while the thought I had on my last 400 was so inspirational, and let me have such an amazing experience, it was incorrect. After college I played on several more competitive ultimate teams, and I had to run many more 400s. I ended up coaching college ultimate and even ran 400s with the team voluntarily. But while the thought was incorrect in a literal sense, it was emotionally true. Each moment of your life is the last time you will live that particular moment. Sometimes these moments are joyful, and sometimes they are painful, and sometimes they are both. Pain is simply an unavoidable part of life. I just hope to live a life that is worth enduring it for.

 

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Alex Korb, Ph.D., is a postdoctoral researcher at UCLA and scientific consultant for BrainSonix Inc. 

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