Do You Have Trouble Sleeping?

The Global Sleep Crisis

0:00This is Hidden Brain. I'm Shankar Vedantam. Across the world, many countries are experiencing a sleep crisis.

0:09In the United States, 50 to 70 million Americans have sleep disorders. In India, almost 60% of adults get less than six hours of sleep every night.

0:23Sleep deprivation can make us groggy and irritable. So, chronic sleep deprivation can rewire our brains and wear down our bodies. It can change how we parent, how we work with others, even what we value.

0:41This week on Hidden Brain, and in a companion episode on Hidden Brain Plus, what happens when a basic human need is jeopardized by an always-on culture, and techniques to help you get a restful night of sleep.

0:56We all know that sleep matters, and we all know what happens when we miss a night of sleep.

When Sleep Deprivation Causes Disasters

1:15At the University of Washington, sleep researcher Chris Barnes has studied what happens when the need for rest and the need to work collide. He says the consequences of not getting enough sleep extend far beyond what most of us imagine. Chris Barnes, welcome to Hidden Brain. I'm happy to be here, Shankar. Chris, you've studied the effects of sleep deprivation for many years. One story in particular has stayed with you. It involves a man named William Rockefeller. Can you tell me his story? So, William Rockefeller was a train engineer in New York,

1:51and he had a route that started early in the morning from Poughkeepsie headed to New York City.

2:04So, the reason William Rockefeller ended up in the news one day was because of something that happened as he was making this train journey. Tell me what happened, Chris. So, as he was operating this train early in the morning, he sped through a section of the track in which he could go 70 miles an hour, ended up going a little faster than that, closer to 80 miles an hour, and continued that speed as it came to a curve. This curve had a speed limit of 35,

2:35but he did not slow his train down to that speed fast enough to avoid a disaster. I understand that he hit the brake, but just not in time? Yes, it was too little too late, and the train derailed, four people were killed, and 60 were injured.

3:02So, when investigators looked into the source of the problem, tell me what they found. Well, initially, the train conductor's statement was that he felt like he entered a state of being sort of dazed or mesmerized while he was operating the train. Later, it came out that likely he actually fell asleep while he was operating the train, and then woke up too late to slow the train down to an appropriate speed for that curve. So, essentially, he fell asleep, and that led him to crash the train.

3:35So, as the train came roaring up to this curved section of the track, presumably he woke up and he hit the brakes, but that was too little too late. Exactly. I understand the train operator also suffered from sleep apnea, Chris? Yes, he had a history of sleep apnea, which is a sleep disorder that is very disruptive to people's sleep.

4:08Essentially, when you have sleep apnea, your airway closes off and you stop breathing, and then usually you choke yourself awake, and this might happen as many as hundreds of times per hour. So, it is quite disruptive to people's sleep, and even if you think you're getting a lot of sleep while you have sleep apnea, the quality of that sleep is poor, and the amount of sleep is usually much less than people think. You can imagine how frustrating this would be to experience sleep apnea, where there are so many of these events throughout the night that you don't even remember all of the awakenings,

4:41because they're just too numerous, and you're kind of groggy when they happen. I understand the National Transportation Safety Board investigated this crash that took place, Chris. Did they identify a lack of sleep or sleep on the part of the operator as the source of the problem? Well, they mentioned several causal factors,

5:12one of which would be his recent change from a day schedule to a morning schedule. So, there's some potential for circadian disruption, in addition to his sleep apnea sort of stacking together as setting the stage for a higher likelihood than would otherwise be the case for him falling asleep on the job. And perhaps it's not surprising that that's exactly what happened to him.

5:37So, this incident took place in December 2013, and a similar story took place in 2001 in the United Kingdom. But this time, the problem was not with a train operator, but with a motorist named Gary Hart. Tell me that story, Chris.

5:58So, Mr. Hart was operating his vehicle, which was pulling a trailer that had another car on the trailer. And he had driven through much of the night. This was an early morning event. And he fell asleep while driving. And his vehicle veered off the road down an embankment and onto some train tracks. He tried to reverse off the train tracks, but was stuck and could not get his vehicle off. So, he exited the vehicle and called the emergency services. And unfortunately, that's when disaster struck.

6:30What happened? So, a train was already on those same tracks. It is his direction. And you can actually hear on his recorded emergency services call, the train actually striking his vehicle. And that train was derailed and deflected in the direction of another train coming the opposite direction, which produced a head-on collision between the two trains that produced several fatalities and many injuries as well.

7:02I understand that 10 people were killed and 82 were injured, making it the worst rail disaster in the United Kingdom in the 21st century. You know, perhaps there were many factors, you could argue, but one of the principal factors was that, you know, Gary Hart drove off the road in the first place because he was asleep. Exactly. Fell asleep at the wheel and woke up as his vehicle was going down that embankment onto the train track.

7:34But that was obviously too late to prevent the disaster from occurring.

7:39So, typically, when incidents like this take place, Chris, our tendency is to blame the people involved, to blame the motorist who fell asleep, to blame the train operator who was drowsy. At some level, of course, these individuals have to take responsibility for what happened. But you say that this ignores a more serious part of the problem, Chris? Yes. So, we usually prefer simple, easy answers. We prefer to look for proximal factors that are simple to diagnose, and then we can dismiss the whole thing, like operator error.

8:12Human error is sort of a catch-all that we often use when we have disasters like these happen. But we don't often ask the question, okay, why did that human error occur? Why did this person fall asleep while they were doing something that is dangerous to do while they're asleep? So, we need to zoom out and look at more systemic factors surrounding that decision without necessarily totally absolving the person who fell asleep on the job. They bear some responsibility as well. But it's never that simple. This is always something that occurs

8:43in the context of many other factors, often which operate in concert, in the same direction, pushing people towards sleep deprivation. So, I mean, it's not like William Rockefeller and Gary Hart had these long histories of accidents and problems. These were one-off incidents, obviously terrible incidents, but they were one-off incidents, which does raise the question, what else was going on besides what was happening in these individual people's lives? Exactly. On other days of driving, they were perfectly safe. They did not fall asleep at the wheel.

9:15And there were other people that day who didn't fall asleep, but those other people, perhaps in the right context, might make the same mistake.

Parenthood and Driving Exhaustion

9:23So, Chris, you became a father to twins in 2019. You already had a three-year-old at home at the time. I'm imagining this was a time in your life when you weren't getting much sleep? Yes, it was overwhelming. The way I like to think of it is imagine all of the challenges and difficulties of a newborn and how disruptive that is to your sleep, and then add a second newborn to that same equation. So, if somebody hands you a second baby and says, here, deal with this as well. So, all of the feeding and changing cycles

9:54are longer, and nobody sleeps well in this situation. The babies don't sleep well. The parents don't sleep well. I certainly didn't sleep very well. And you also had another little one at home at the time. Yes, I had a three-year-old who also required attention and love and caring for the cumulative duties at home between the twins and my three-year-old were quite high. So, I actually have very little memory of that time period other than sluggishly washing bottles

10:27and changing diapers and just trying to survive. Yeah. So, one night you get an urgent call from your mom. Describe for me what she said and what happened next, Chris? So, for context, my parents, especially my father, had been in poor health for a few decades. And so, some corner of my mind was always concerned that the next call I get from my mom could be that call that perhaps my father was dying. So, in this particular occasion,

10:58my mother called me at three in the morning. And that timing is already indicative that something is not going well. So, she called me quite distressed saying that she had found my father lying on the floor, unresponsive, passed out. It wasn't clear how long he had been there, but they were on their way to the hospital. So, my first thought was, okay, this is the call I've been expecting. I need to go see them right away.

11:28Like, this might be my last chance to see my father while he's still alive.

11:36So, I'm imagining that you probably hopped in the car and raced to the hospital, Chris. Exactly. So, the hospital was about an hour from my home. And so, I immediately got into the car and drove down there despite it being roughly three in the morning in a time period in which I was already not sleeping much anyway.

12:00So, tell me what happened once you got to the hospital. How was your dad? I got to the hospital and spent a few hours talking with my parents. My dad, turns out, he was okay. It was just a scary event that wasn't so dangerous to his health after all. So, he was okay. I had that chance to spend some time with him. But I still had two babies at home and a three-year-old. And my wife at the time was the only one looking after all three of them.

12:29So, I'm imagining you must have jumped back in the car and now try to race home. Exactly right. So, I felt both physically and emotionally exhausted. The physical exhaustion was due to an accumulation of sleep deprivation over the preceding weeks and more. And plus the wakening and the rapid drive down to the hospital at 3 a.m. Plus the emotional exhaustion of thinking that perhaps this is when my father's about to die.

12:59So, those two stacked on top of each other just left me feeling completely drained. My eyes were bleary. I did not crash on the way home. But I did have a moment where I fell asleep while driving on the freeway for probably a few seconds. I can only guess. But my estimation, it was somewhere around three to five seconds going straight on I-5. at highway speeds.

13:29Now, three to five seconds going at 60, 70 miles an hour, you cover a lot of distance in three to five seconds, Chris. Yes. And as soon as I woke up, I had this jolt of fear and guilt and anger at myself knowing that I had just done a really stupid thing. That there is no way I should have made that decision. that I just put not only my life at risk, but all the drivers around me. Sometimes I still think about that moment.

14:00And I think about the fact that in the multiverse, some swath of that multiverse, I am the villain in some family's story. Because as I fell asleep, I crashed into another vehicle and caused some tragedies.

14:18So we've been talking about individual stories here, and people can say, well, these are anecdotes,

Late Night Sports and Traffic Accidents

14:24but there's data as well. One comes from places like Taiwan and Singapore where traffic crashes often seem to follow a pattern. What do we see in these places, Chris? Yes, this is quite an interesting pattern that my co-authors and I found when my co-author, Sam Yam, he's a professor at National University of Singapore who was interested in the idea of soccer being a global phenomenon. And so what we hypothesized and what we found empirically

14:54was that there is a spike in car crashes, both in Singapore and Taiwan, following major soccer games that are played in Europe. And presumably that's because the games in Europe are played at a time when it's presumably early morning in Asia? Exactly right. So the soccer games in Europe are played at reasonable times for people to watch in Europe, which are generally unreasonable times for people to watch in Asia. And soccer is probably not as popular per capita in Asia

15:26as it is in Europe, but there are a lot of people in Asia and many of them are soccer fans. And from some of our preliminary surveys that we did, we found that a surprising number of people in Asia are staying up very late into the night or very early in the morning to watch these games live. And this is, unfortunately, considerably cutting into the sleep that they get that night. It appears that as a result of that missed sleep, their risk of a car crash goes up. And so that's exactly what we observe in the data. You studied taxi crashes

15:58with a large taxi company in Singapore and also another data set which tracked really all auto crashes in Taiwan over a period of a few years. Exactly right. So we found the same general pattern in these two very different locations in Asia. And there's an interesting nuance on top of that as well, that the effect scales with the popularity of the soccer teams that are playing in Europe. So if those teams are more popular, then we see a larger spike in car crashes the next day

16:29in both Singapore and Taiwan.

16:40When we hear tragic stories of people making grave mistakes as a consequence of sleep deprivation, it's tempting to believe that would never happen to us. That could never happen to us. But the tragic stories we hear are only extreme examples of a universal truth. Sleep deprivation can profoundly change our judgment and our behavior.

17:04When we come back, the complex consequences of not getting enough sleep and what you can do about it. You're listening to Hidden Brain. I'm Shankar Vedanta.

17:20How often do you lag through the day, tired and foggy, dreaming of the minute you'll hop into bed for some sleep? You tell yourself that you'll change things in your lifestyle to get more sleep on a regular basis. But that day never comes, and you find yourself stuck in cycles of chronic sleep deprivation.

17:47At the University of Washington, Chris Barnes says that while most of us know the consequences of poor sleep, we underestimate how profoundly it can affect us.

17:59Chris, we've all heard about how a lack of sleep can affect our physical health and even our mental health, but you say there are more insidious effects. One unfolded in 2018 when World Cup soccer fans were gathered in Moscow, and it involves a driver named Chinggis Anarbek-Hulu. Paint me a picture of what happened that day, Chris. So, Ulu was a taxi driver driving in a pretty crowded environment because of the soccer game that was going on, and he suddenly veered

18:29onto a sidewalk and accelerated, running his car into a crowd of people there. Immediately after plowing into the crowd of people, he exited his vehicle and fled the scene. He ran away. Do we know what happened that day and how the accident came about and why he ran away, Chris? Yes. An investigation, an interview of Ulu, indicates that he had been working for approximately 20 hours straight on shift, and he was clearly quite tired

19:00while he was driving. And according to his perspective, he was drifting off and was looking to allow a pedestrian to pass by, and then he says that he hit the accelerator instead of the brake. So, he had intended to stop and had unfortunately done the opposite. So, what strikes me

19:33about the story, Chris, isn't that he just fell asleep at the wheel and ended up hurting lots of people, but that he made the split-second decision to flee the scene afterwards. In some ways, the story speaks to some of your research because you've studied how a poor night's sleep can damage our ability to make good decisions, can damage our judgment. There's a large body of research to indicate that sleep deprivation undermines our decision-making in general, and I do have some research in this area. The general theme

20:04across this research is that we are much worse decision-makers when we are sleep-deprived. This is especially the case for any decisions that we make that are non-routine, that are novel, and you have to figure things out on the spot rather than simply enacting a previous decision. So I could imagine that an unexpected incident like a car crash or running into people would be a very novel situation in which you have to rapidly make a decision, and you are impaired in that decision process.

20:34So it's perhaps not surprising that people make poor decisions in these contexts. So you've looked not just at how the quality of our work might suffer as a result of sleep deprivation, but also you've looked into the relationship between a lack of sleep and unethical conduct?

Sleep Deprivation and Unethical Conduct

21:01Yes. This was some of my favorite research that I've ever engaged with, and the idea here is that people in the context of work are faced with many temptations. So you might have a temptation to cut some corners, maybe tell a small lie, maybe take credit for someone else's work, maybe blame somebody else for your mistakes. Whatever form of work you have, there's probably some form of unethical behavior that you could engage in that might have some personal benefit.

21:32Fortunately, most of the time, most of us are able to resist those temptations, and that's great. But there's clear evidence to indicate that when people are sleep deprived, their ability to exert self-control, their ability to resist impulsiveness and cave to those temptations is eroded. So we see that when people are sleep deprived, their likelihood of behaving unethically tends to go up. And what I find especially fascinating about this is that you can see the same person

22:02behaving more unethically or less unethically on different days based in part on how much and how well they slept the night before. And when you say sleep deprivation, Chris, are we talking about an hour less of sleep, five hours less of sleep? I think of this as a relatively continuous scale where you will get the worst results if you get zero hours of sleep, but even small amounts of lost sleep matter. There are some pretty compelling studies, some of my research, but also a much larger

22:32body of research that finds that even an hour of lost sleep can have meaningful effects on outcomes that we care about like workplace injuries or work engagement or moral awareness. There are even some nap studies that allow people an opportunity to have like a 10 or a 15 minute nap. And that amount of sleep is enough to move the needle on some important outcomes like performance. Some of my research indicates that when people are sleep deprived, their moral awareness is lower. So they're less likely to even appreciate that there's a moral aspect

23:03to the decision that they're making. They just treat it as a non-moral type of decision rather than seeing the layers of nuance that are often entailed in a moral decision. So that their sleep deprivation sort of simplifies their decision process in a way that fails to engage their moral frameworks. I want to talk about another overlooked consequence of sleep deprivation. In 2014, the ESPN sportscaster Courtney Cronin came under fire for a live television appearance.

23:34Tell me what happened, Chris. So she had called in to a live ESPN radio show. She's an ESPN sports analyst. And she was covering the NFL Combine in Indianapolis. She joins us on the Home of the Bears ESPN 1000 on the hotline. And she was having some technical difficulties with her earbuds. And you can actually see in the recording that she was getting some very annoying feedback. And you can see the frustration mount

24:05on her face. And then at some point she rips out her earbuds and says an expletive live on the air. And everything else that kind of unfolded. All right. So Courtney Cronin blamed this outburst on sleep deprivation. But at a larger level, Chris, can you talk about how a lack of sleep can make us turn molehills into mountains?

24:31Sleep deprivation has some pretty powerful effects on moods and mood regulation. So we see that when people are sleep deprived, they tend to have higher levels of irritation and frustration and anger, sometimes higher levels of depression. And then emotional control becomes more difficult. And this is due in part to the way different parts of our brain work together, the prefrontal cortex and the amygdala and the way that they interact with each other. That self-regulation

25:01is less effective. So people's emotions tend to be a lot more lumpy and wavy and big. And exactly as you say, when we're sleep deprived, something that would normally be more of a molehill looks like more of a mountain. And so we get big emotional reactions when people are sleep deprived.

25:23There's even some evidence that sleep deprivation may be connected to major disasters. On March 23, 2005, the Texas-based oil company BP suffered one of the worst industrial disasters in history. Tell me what happened and how sleep might be implicated in what happened, Chris. So they had overfilled one of their fuel towers and one of the automated systems then vented some of this fuel, which was then ignited, causing an explosion,

25:53raining down this flaming fuel on the trailers of the employees down below, causing several fatalities and injuries as well. So when they later investigated what happened, one of the potential causal factors was about a month straight of 12-hour shifts for the employees who were involved. So this was a tremendous accumulation of sleep debt from missed sleep over this time period. It wasn't just the 12-hour days,

26:23but also the long commute. Some of these employees had two-hour commutes on top of these 12-hour days. So there was a lot of missed sleep in the period leading up to the incident. I mean, there were eventually 15 workers killed and 180 people injured. And according to the investigation, one of the people involved had had an accumulated sleep debt of 43 hours. That is just enormous, Chris. Yes, so this is why I'm a little skeptical when people say

26:55missing an hour or two or three is not a big deal because it's not just that one or two or three hours. It's the accumulation of many such nights of sleep debt. There was even a recent report that looked at the relationship between nuclear disaster and sleep deprivation. Tell me what this found. So it is perhaps not surprising that several of these events tend to occur very early in the morning. So both Chernobyl and Three Mile Island, these events happened

27:25between 1.30 in the morning and 4 o'clock in the morning is sort of the most important timing of these events. And these are times at which people tend to be at a poor state of mind from their circadian rhythms, pushing them towards sleep. And when they are working these shifts, it means that they have a work shift that is misaligned with their own natural circadian rhythm, which tends to lead them sleep-deprived. And these are very complicated systems that they're working with, which is especially a problem when there's something novel that occurs.

27:57So something goes wrong that doesn't typically go wrong, and now you have to figure out on the fly how to deal with this in a state in which you are impaired from sleep deprivation. So of all the times at which these disasters tend to occur, that is the most dangerous time, and that's when we see that it has happened, at least in those particular events. You know,

Daylight Saving Time and Workplace Injuries

28:18many of us are sleep-deprived, but we're not in charge of a nuclear plant. But of course, some people are in charge of a nuclear plant, and they have circadian rhythms too. Yes, they do. And unfortunately, these nuclear plants have to be operated 24 hours a day, which means some of these employees have to work at circadian unfriendly times where their biological drive is to sleep, and instead we have them wake and operate complicated machinery. And then they go home, and their schedule says they should be sleeping, but their biological drive is to be awake

28:49and do waking activities. So when we have such circadian misalignment, not only are we less alert and less effective when we are trying to do waking activity, but our sleep then becomes much more challenging as well. I want to talk about one other common source of sleep deprivation. On March 11, 2018, a sightseeing helicopter crashed into the East River off the Upper East Side of Manhattan. Five people ended up being killed. Tell me what happened and how sleep might be connected to the incident, Chris.

29:21So this was a pilot and five passengers taking a tour in New York City. So they were flying near the Upper East Side. And there were witnesses that said this helicopter started going down fast as if it were going to land on firm ground. And unfortunately, it did land in the water and then capsized and turned over sideways. And the pilot was able to escape, but the passengers, they had multiple layers

29:52of harnesses and they were unable to escape. So they all died. They all drowned.

29:58When investigators try to find out what caused the crash, Chris, what did they find? One of the passengers was turned sideways with his legs outside of the helicopter, which put his supplemental harness sort of dangling towards some of the flight controls. And so he leaned back and then suddenly leaned forward and this pulled his supplemental harness against the fuel release control.

30:29That's what depowered the helicopter such that it started its rapid descent.

30:36So clearly this accident had a direct cause, but there was also potentially an indirect cause. The date of the crash was March 11, 2018, as I said. It was a Sunday, but it was also the start of daylight saving time in the United States. On that Sunday, the clocks in many parts of the country jumped forward by an hour overnight, meaning that people got

31:07one hour less of sleep. So it says 6 a.m. on your watch, but your body clock feels like it's still 5 a.m. What do we know, Chris, about the relationship between that lost hour of sleep on daylight saving time weekend and accidents and crashes from nationwide data? Well, there are several studies that examine this. Some of my favorite studies examine car crashes. So the initial study published in 1996 found an elevated probability of car crashes

31:37following that spring daylight transition with a noticeable increase in both crashes and traffic fatalities. There was a follow-up study in, I believe it was 2018, that basically replicated that pattern. So we see a very clear spike in car crashes following that spring transition into daylight saving time. One of my own papers looks at workplace injuries and we deliberately studied mining injuries based on the idea that mining occurs underground.

32:08So any changes in daylight pattern distribution would be parsed out of the study. So we examined about a half a million mining injuries over a 25-year period. And surprisingly, we found a spike on the Monday right after the change to daylight saving time of 5.6% in mining injuries and an even larger spike in injury severity as operationalized by number of lost work days due to the incident.

32:42Many of us don't get the recommended amount of sleep every night. We know it can affect our well-being, our memory, our mood. But what's more surprising is that a lack of sleep can cause poor decisions and even unethical behavior.

32:57The solution seems simple. Sleep more. But of course, if the solution were really that simple, the problem would be solved by now.

33:06When we come back, getting to the root of our problems with sleep. Also, in our companion episode on Hidden Brain Plus, we take a deep dive into the effects of sleep deprivation on leaders, managers, and workplaces. Turns out, sleep and sleep deprivation ought to be factors when you're deciding whether to work at a company or to invest in one. If you're a manager or a leader, you need to hear how sleep can affect your judgment and decision-making. If you're already a subscriber, that episode is available right now

33:37in this podcast feed. It's titled, How Sleep Deprivation affects leaders. If you're not yet subscribed, please sign up at support.hiddenbrain.org. If you're using an Apple device, go to apple.co slash hiddenbrain. You'll instantly have access to all our subscriber-only content, and your support helps to sustain the reporting, writing, and fact-checking behind every episode of the show. Again, that's support.hiddenbrain.org or apple.co

34:07slash hiddenbrain. You're listening to Hidden Brain. I'm Shankar Vedantam.

34:17This is Hidden Brain. I'm Shankar Vedantam. Do you have questions or comments about sleep and how it affects your life? Do you have a personal story about the effects of sleep deprivation that you would be willing to share with the Hidden Brain audience? If so, please find a very quiet room and record a voice memo on your phone. Two or three minutes is plenty. Email the audio file to us using the address feedback at hiddenbrain.org Use the subject line sleep. Again, that email address is feedback

34:48at hiddenbrain.org We often think of sleep deprivation as a personal problem, something that affects how we feel, how productive we are, how well we can get through the day. If we are tired or cranky from not getting enough rest, we assume the consequences will land on us.

The Science of Sleep Quality

35:10At the University of Washington, Chris Barnes studies the science of sleep and the effects of sleep deprivation. He says the stakes are far higher than we imagine. When people are chronically exhausted, that doesn't just affect their own health. It can shape the safety of entire communities. Chris, how much sleep do most people require and how much sleep do most people get? So, most of us need between seven and nine hours. Of course, people hear that and they hear, oh, okay, seven is fine.

35:40So, you might be one of the people who needs seven, but you might be one of the people who needs nine. So, most of us are in that range, seven to nine. For school-age children, ten or maybe even more for the youngest school-age children would be best. Unfortunately, neither children nor adults are typically getting as much sleep as they should. Almost all of those people who are sleeping six hours need more than six hours. Most of them probably need seven to nine like everyone else. Unfortunately, a large number of people believe they are short-sleep superheroes

36:11and that maybe it's fine for everyone else to get eight hours of sleep, but I'll be just totally fine if I get four hours of sleep because I'm somehow above the need for sleep. It's an unfortunately common belief. Can you talk about the importance of not just enough sleep but of getting deep sleep? Yes. So when I talk about sleep, I usually talk about both sleep duration as well as sleep quality. And sleep quality is a little bit harder to understand, but the central

36:42aspect there is getting into really deep sleep. The simplest way to think about deep sleep is if it's kind of difficult to wake you out of that sleep, that's a good indication, at least on the surface level that you're getting to that deep sleep. So we can really divide our states into three states. So there's waking, there is REM sleep, rapid eye movement sleep, and there's non-rapid eye movement sleep. And when we get to this deep N3 non-rapid eye

37:12movement sleep, there are some very important recovery processes that happen more so during that aspect of sleep than during REM sleep or waking activity. I do say that both REM sleep and deep non-REM sleep are both quite important, but that deep non-REM sleep can be kind of hard to get sometimes.

37:32Let's talk about some interventions that can help us improve our sleep. Perhaps we should start by talking about the relationship that many of us have with our phones.

Smartphones and Blue Light

37:42Yes, our phones are amazing devices that have lots of beneficial effects and increasingly, clearly some harmful effects as well. So my colleagues and I conducted a study in which we examined smartphone use late at night. We find that using these devices late at night tends to come at the cost of sleep and as a result people go to work the next day tired and they're not their best selves and they tend to be less engaged at work the next day. So there's

38:13sort of an ironic effect here where you might be trying to squeeze in a little bit more work late at night on your phone, but then you work less the next day as a result. So there's not really a net gain there, but there is a net loss to your sleep and of course all the bad things that happen when you get less sleep.

38:31So you and others have also done research on the use of blue light filters. Talk about this work, Chris. Does it help us when it comes to using our phones late at night? The ideal solution here is not to use our phones late at night, but it is good to have some other tools that can help to mitigate some of these effects. blue light unfortunately suppresses the production of melatonin, which is a chemical that is useful in the process of falling asleep. So when we are using our phones right next to our face, shining that blue

39:01light into our eyes, we're essentially sending a signal to our bodies to stay awake. So one way to deal with this is to put on glasses that filter out that blue light, which has the most powerful effect on circadian system. So if that blue light doesn't reach your eyeballs, then it won't have as much of an effect. So I want to be careful to note that these blue light filtering glasses are not a magic bullet. They are not going to fully solve the problem, but the data do indicate that they can be a useful partial solution to some of the circadian

39:33dysregulation issues that we tend to face in our modern society. I'm wondering if you can address an elephant in the room here, Chris. One of the cultural undercurrents, especially in American society, is that people who are high status often claim that they need less sleep or they're getting less sleep. And in some ways, it sends a message to everyone else that being sleep-deprived

40:03is in some ways a sign of being important. Can you talk a little bit about this and how in some ways that message runs very counter to the message that you are preaching?

40:13Yes, so there is an idea floating around out there that if I'm really important, then I don't have time to sleep. And that if I am especially capable, that I have less need for sleep. Now I'm at the point where I actually wish this gym would open earlier and I actually can't sleep in. And I love it because the morning is the best part of the day. I know there's some out there that say, whoa, whoa, I need eight. I say just sleep a little faster. The reason I wake up at 430 in the morning is no one else is awake yet. So that gives me the opportunity to do

40:44things that I need. Rich people don't sleep eight hours a day. That's a third of your life. It ain't between your entire day with little to no sleep.

Bragging About Sleep Deprivation

40:53So my colleagues and I actually conducted some research about people bragging about their sleep. And our question was essentially, like, given all the evidence that we have so far that sleep deprivation has such bad effects on work, why would people do this? So there's sort of two paths to status gain by bragging about your sleep deprivation. So one path is that your colleagues might see you as strong. Like, you're so strong that not even sleep deprivation can hold you down. And indeed, we do find

41:24this, that bragging about your sleep deprivation can increase perceptions of your strength, which in turn increases perception of your status. The other path is self-sacrifice. So people might see you as sort of honorable, like, wow, you're willing to sacrifice your sleep so that you can work more on behalf of our group. And that is a second way to gain status. What I find especially interesting is there's a gender wrinkle here where the strength path is most visible for men.

41:56So when men brag about their sleep deprivation, they tend to be seen as stronger and they gain status that way. They don't tend to be seen as more self-sacrificing by bragging about their sleep deprivation. And it's the opposite for women where they tend to be seen as self-sacrificing and gain status that way, but they're not perceived as stronger for bragging about their sleep deprivation. So big picture here, it appears that there's some rationality here where people suspect that there are some social gains that they

42:26can get from bragging about their sleep deprivation. And some of our data bear this out to some degree where, yes, if you brag about your sleep deprivation, you might actually be able to gain status, which is quite unfortunate and in the long run ultimately self-defeating.

42:48A reminder, have you experienced serious adverse consequences of sleep deprivation? If you have a personal story you'd be willing to share with a Hidden Brain audience or a question or comment about this episode, please find a very quiet room and record a voice memo on your phone. Two or three minutes is plenty. Email the audio file to us using the address feedback at hiddenbrain.org. Use the subject line sleep. Again, that email address is feedback at hiddenbrain.org.

43:18Chris, we talked earlier about how the switch to daylight saving time is associated with an uptick in accidents. There's been a lot of debate about whether or not daylight saving time should be abolished because of these health hazards. What do you make of this debate, Chris? Where do you come down on it?

43:39So the science is very clear that the change to daylight saving time in the spring in particular is quite disruptive where we see an increase in heart attacks and car crashes, other harmful effects like that. The fall change is perhaps less disruptive where we gain that hour that doesn't appear to be very beneficial but it's not quite as harmful. Beyond just the transition periods, being in daylight saving time is a prolonged multi-month

44:10exposure to a circadian misalignment. and the best example of research that makes a strong case for this is there's a really cool paper that studies just one side versus the other of a time zone. So basically you're examining people who are at the western edge of the time zone and the eastern edge of the time zone and that evidence indicates that when we are in the edge of the time zone that gets daylight later

44:40in the day that tends to be worse for our health including higher rates of cancer than when we're at the edge of the time zone that gets daylight earlier in the day. So we should for our health sake we should prefer that daylight to be shifted early rather than late. My own research examines work injuries as an outcome of this. There's a large body of research to indicate that we are generally going to be healthier and have better outcomes when we have permanent standard time if we

45:11don't change to daylight saving time and we don't have permanent standard time. Unfortunately when we discuss this topic people think about their summer barbecues and what light patterns would they like for their summer barbecues. I like summer barbecues. I get it but I think people are not very well informed about the downsides of the current daylight saving time policy.

Societal Policy Solutions for Sleep

45:38Some people even say let's make permanent daylight saving time so that I can always have that sunlight in the evening. Are there other policy recommendations that you have for improving sleep quality at a societal level not just at the level of individuals? Yes. Daylight saving time should be the easiest one to change. Another low hanging fruit that we're seeing some progress on is school start times. I remember when I was in high school school started at 7.30 which is an

46:08unreasonably early time for a teenager. That's if you can imagine for an adult starting their work day at like 4.30 in the morning. That's kind of like what it's like to be a teenager who has school starting at 7.30 in the morning. So there's a pretty big movement that has had a fair amount of traction to push school start times later in the day. So I think that would be a major win. One that would be a bit more difficult to implement but still could be quite powerful would be to apply some of

46:38the lessons learned in sleep regulation that we see in really dangerous industries like transportation and medicine. So you see for pilots and truck drivers and physicians there are some rules in how we set up their schedules. Rules for the maximum number of hours they can work in a given period. Rules for how rapidly we can rotate them from one kind of shift to another kind of shift like from day to night or night to day.

47:08These rules are there because if we don't follow those rules then really bad things tend to happen. People crash their cars, they crash their planes, they make medical errors. We still have a lot to learn and we can improve those regulations in those dangerous industries but I think we could also take some of those lessons learned and apply them outside of those industries as well. So not everyone has such a dangerous job that if they make a mistake a bunch of people are going to die but a lot of people still have important jobs nevertheless and if they make mistakes

47:39it's still going to cause some sort of a problem. So I think we could apply some of those same ideas to regular everyday jobs and I think we might find that companies are more open to this than we might expect. I'm wondering whether you applied any of these ideas to your own life Chris when you have trouble sleeping what do you do? So I will try to do a self-check how do I feel right

48:09now and this is obviously imperfect because we're often unaware of how impaired we are but it's still a useful exercise to engage in that's a little bit informative and so if I feel like I'm drowsy I'm not at my best I'm not most alert then I will do a simpler task maybe answering some emails maybe I'll tinker with some slides that I'm using for a class and if I feel more energized that's when I'll do the more tricky things like maybe giving a PhD student some feedback

48:39on their dissertation so to do a good job in that I have to be especially diligent and focused and so I might change the order of those tasks depending on how I feel in that moment more than 400 years ago Shakespeare described sleep as nature's soft nurse we've long known that sleep is a useful remedy for what ails us whether we

49:10are in distress or sniffling our way through a bad cold sleep is also an essential tool in confronting another problem intense physical pain we recently received a story on this topic from a listener named David many years ago he was in a bad motorcycle crash his lower left leg had to be amputated for years for years he suffered from phantom pain in the limb that was no longer attached to his body I would

49:40get this unbelievable sudden jolting pain that would hit me and just wake me from my sleep it was really unbelievable David David's body needed sleep to heal from the trauma of the crash but the pain prevented him from getting that sleep it was a vicious cycle finally in 2019 he had a procedure called targeted muscle re-innervation that's where they go in and they find the nerves that's sending the phantom limb pains to the brain

50:11clips the end of it off and reattach it to a quote active nerve kind of completing the electrical circuit instead of the nerve that's sending the phantom limb pain just dangling there going I don't know what I'm going to do I'm going to send pain signals to the brain the procedure hasn't been a cure-all but the jolting pain that used to wake him up is now gone in its place is something David considers an annoyance it's like the pins and needles sensation when your

50:41arm falls asleep it's not really painful but it's annoying you know especially when I get quiet down at night when I lay in bed but it's manageable the pain that David experienced after his leg was amputated is a powerful reminder that pain is not just in our bodies pain especially chronic pain is also about what's happening in

51:13our brains when we come back psychologist Rachel Zofnitz returns to the show to respond to listener questions and stories about pain and the role that our minds play in managing it you're listening to hidden brain I'm Shankar Vedantam this is

51:50hidden brain I'm Shankar Vedantam if you stub your toe or accidentally touch a hot pan on the stove your pain will be immediate and intense we all experience these moments of acute pain but with time the agony recedes chronic pain is different it's the migraine that overtakes you day after day it's the ache in your hip that won't go away the cramp in your gut that wakes you every night chronic pain can rob us

52:21of the ability to work the urge to exercise even the desire to do fun things with friends we

The Biopsychosocial Nature of Pain

52:30talked recently about chronic pain and how to cope with it with Rachel Zofnes a psychologist at the University of California San Francisco If you missed that episode it was titled How to Combat Pain Rachel is the author of Tell Me Where It Hurts The New Science of Pain and How to Heal Today she returns to the show to respond to listeners questions and comments about her work Rachel Zofnes welcome back to Hidden Brain One of my favorite ever podcasts

53:00I'm so happy to be here Rachel we talked in our earlier discussion about how you frame pain as being biopsychosocial in nature explain that term to me this is one of the most important words when we think about pain one of the biggest myths we've been sold is that pain is a purely biomedical problem something to do just with anatomy and physiology that requires a purely biomedical solution usually in

53:31the form of pills and procedures that is the myth we have been sold for many many decades but 65 years of neuroscience tells us that that isn't actually true pain is biopsychosocial so if you imagine a Venn diagram with three overlapping circles these are the factors that contribute to pain we have the biological factors that contribute to pain in one of the circles psychological

54:02factors that contribute to pain and sociological factors that contribute to pain and pain lives in the middle of these three domains of health and to briefly say in the biological domain of pain we have the things that your listeners will have heard the most about we have genetics tissue damage system dysfunction inflammation diet exercise and sleep those are very very

54:33important when it comes to pain but what I want us all to notice is that if we're only focusing on the bio domain of pain we are missing two-thirds of the pain problem I'd like to share a story that gets at how environmental and psychological factors can affect our experience of pain this story comes from a listener named Bruce I had chronic back pain for over 25 years and my wife had

55:03chronic migraines and we eventually got divorced and a couple of years later we happened to be together at the same time at a graduation ceremony and she saw me sitting in a chair and she said how come you're not leaning back and I said why would I lean back and she said well you always have back pain and that's the only way you can get out of it and I said I haven't had any back pain for like a year and a half she looked at me and I said how are your migraines and she said I haven't had migraine for like

55:33also about a year and a half and we realized we had been divorced for two years and all of our chronic issues had gone away does Bruce's story surprise you Rachel no it doesn't particularly surprise me that's not how pain works for everyone but it certainly shows us very well that social factors which is one of our three domains of pain are fundamentally important to the pain experience in so

56:04many different ways so I first started studying pain neuroscience when I was an undergrad at Brown University I was paired with a pain neuroscientist and wrote my honors thesis on pain and I remember thinking I understand intuitively of course that pain is biological and I even understand that pain has emotional aspects to it but I couldn't understand this social domain of pain so when I was writing tell me where it hurts I really went down the rabbit hole to explore

56:35the research and I found so much science behind this so research has examined all these different ways that social relationships change our bodies and change our pain so one thing that researchers have examined is the impact of healthy relationships versus toxic relationships on our bodies and on our physical health and I want to define those terms a little bit when I

57:05say a healthy relationship I mean a relationship that is supportive and respectful and loving low stress you know two people generally speaking lift each other up and there's a word for this in science those are called pro-social relationships and toxic relationships are relationships that are typically high conflict high stress they're characterized by things like gas lighting or estrangement a lot of conflict and each

57:36has a different neurobiological impact on the human body healthy relationships it turns out do some of the following things they boost our serotonin which of course is a neurochemical involved in mood it bumps our dopamine which is a reward chemical it also increases brain levels of endorphins endorphins are our endogenous homemade

58:07opioids healthy relationships also lift our mood they reduce muscle tension they bump our immune functioning and overall healthy positive relationships turn pain volume down in the brain the opposite is also true it turns out that toxic relationships which again are characterized by things like gaslighting estrangement conflict and stress do the following they trigger

58:38an inflammatory response in the body they trigger a sustained stress response so over time your body can be stuck in fight or flight they increase muscle tension we all know that the more tense our muscles are the worse pain feels they reduce levels brain levels of opioids it can trigger immunosuppression and overall all told toxic relationships turn pain volume up in the brain so social health is intimately connected to our

59:08physical health always and of course that affects our pain so this story was mind blowing and a little bit funny I wonder if listeners are chuckling to themselves I certainly did but no overall it isn't that surprising we've talked on Hidden Brain about the idea of mindsets and how they can profoundly shape our physical and mental health we received this message from listener Donna she had a comment about a particular mindset that can often seep into how we treat many medical conditions including

59:39pain I've been struggling for years with interstitial cystitis which is painful bladder syndrome and there's really no known cause for it or cure for it and millions of especially women suffer from it for the last couple years I've been really struggling with it in a one of the worst flares of my life and I've gotten to places even after trying everything it wasn't helping at all where I felt

1:00:10like I didn't want to live if I needed to be just enduring constant pain living extremely defensively around being afraid to eat anything being afraid to do anything that could cause me stress because that would flare my pain too and just basically living in constant fear and I think it really hit me when there's this idea that it's a perceived danger that was causing the pain here I'd been going to war to try it like basically war against my body I felt

1:00:41like I was broken I felt like my body had betrayed me and the more I was doing to try to combat that the worse I was feeling and instead when I realized that basically my brain was just afraid and that I needed to soothe myself and honestly that shift in mentality I'd been in pain for a year and a half and within a few months I now am living normally again I have the occasional flare day but for the

1:01:11most part I can eat what I want I can do what I want and I believe that I am okay there's a word we hear over and over again in Donna's message Rachel and that word is afraid talk about the feedback loop between pain and fear oh gosh that story Donna's story just hit me so hard there is a notorious and terrible feedback loop between pain and fear pain triggers fear fear amplifies pain

1:01:42the higher pain volume goes the more afraid we become and that actually is adaptive because pain is our body's danger detection system it's our warning system and it exists to keep us safe so you know if you break your ankle while you're on a run your body will give you danger messages and tell you stop running you need to make sure that nothing is wrong with your body you should rest you should seek help you should ice you shouldn't run on that broken ankle if you do you will do grievous harm to your body

1:02:13that is adaptive and important and fear is something that actually stops us in our tracks and it forces us to pay attention the problem is that with chronic pain we know that the science of chronic pain is very different than acute pain and so we actually know the details of how fear amplifies pain which I think is so fascinating fear is part of the stress family so worry anxiety fear even catastrophizing

1:02:43all of those things are known to change our physiology to amplify pain volume in the brain fear activates our central nervous system it increases our heart rate and our muscle tension it activates our immune system and it activates our amygdala the part of the brain we just talked about that is responsible not just for emotions but also for pain and if our amygdala is in a state of threat pain volume will go up so it's

1:03:13really important for us to notice what are the things that are activating the fear and what can we do to reduce our fear of pain and what I loved about Donna's story was that she said it's like music to my ears that when she learned more about pain and when she understood her pain better pain volume started going down so she noticed this relationship between understanding pain better and what

1:03:43the messages mean and what they don't mean and how high or low her pain volume got and the more she read about pain and the more she learned about pain the better she started to feel and that's exactly what we want when we come back is there such a thing as fake pain you're listening to hidden brain I'm Shankar Vedanta this is

1:04:20hidden brain I'm Shankar Vedanta when you're in pain and looking to a doctor for help there can be few words more frustrating than it's all in your head when someone says this it feels like they're saying your pain isn't real you don't have a broken bone or a torn tendon so your pain shouldn't exist but as we've discussed with psychologist Rachel Zarfness pain isn't just about biology it's also rooted in our emotions in the circumstances of our daily lives and the

1:04:51societies in which we live Rachel researchers have long observed that pain is underdiagnosed and undertreated in women I'd like to play for you a message that we received from a listener named Fei five years ago I suffered a severe third degree scald on my right thigh for a third degree scald I should have been given pain killers when I asked for pain relief the doctor dismissed me you are a woman you can

1:05:21handle childbirth and born pain is second to the pain of childbirth so no pain killers for you it was a mess and the care was shockingly unprofessional you can handle childbirth so no painkillers for you Rachel it's been decades since we started to see academic studies about disparities in pain treatment between men and women and between people from different racial backgrounds black and Latino patients are often prescribed pain medicines at lower rates than white

1:05:51patients how is this problem being addressed by the medical community oh god it's a mess we continue to see these great discrepancies in both for people of color and also for women you know culturally men are encouraged to be tough and to be stoic you know if you think about even the language around it you're told to man up and take it like a man right but I actually humbly submit and research supports this that

1:06:22women have it much worse as you mentioned in the beginning women are often dismissed and marginalized and told that pain is all in their head and there is a long history of misogyny in medicine you know we hear about heart disease and you think it applies primarily to men heart disease is the leading killer of women in part because women who go to the emergency room with heart issues are told that it's just emotional it's just stress or anxiety and they are sent home so what I'm seeing is there is

1:06:52more awareness of this and that makes me happy but I'm not sure it's playing out into treatment and diagnosis the way that it should so about 20 years ago a hidden brain listener named Jessie was walking down the sidewalk she slipped and broke her tibia and fibula in five places here she is they inserted a metal rod into my leg and there are nails at the ankle and the knee

1:07:22and once I was technically healed I found that I was continuing to experience pain in this leg kind of chronically over for years it still continues and the first time I went to have it checked out I went back to the surgeon who performed the surgery and they did an x-ray and they looked at the hardware and he said to me look it's perfectly healed

1:07:53and there are people who have had this surgery that go on to run marathons there is nothing wrong with you and and I took that to mean that this is my problem it's my fault that I'm feeling this pain and that you know has led to feelings of hopelessness around this pain so

1:08:24again thank you I really appreciate your program Rachel talk about the idea of real and fake pain and why this continues to be so persistent in medicine today I want to say this really clearly there is no such thing as fake pain pain is never all in our heads pain is always real so Jesse your pain is real all pain is real all pain is biopsychosocial and when I hear stories like this when patients come to my office

1:08:56here is that our healthcare providers aren't being told the true story about pain and then they're passing on to patients this lack of information and education and it's not our doctor's fault by the way like doctors go into medicine to help and to heal but we we know that doctors aren't getting the pain education they want or deserve and so they're burning out and what you heard from Jesse's story is that she was told that her pain is purely biomedical

1:09:28in nature her pain must be just to do with anatomy and physiology and the doctor didn't see anything wrong on the scan therefore Jesse should have no pain pain is a biopsychosocial phenomenon and the way I like to talk about this and tell me where it hurts and just in general is that we always have a pain recipe there's always a recipe of ingredients that create the pain experience there's biological factors in that recipe there's social and sociological ingredients and there's also psychological

1:09:59ingredients like emotions because our amygdala is always involved in the pain experience and so what Jesse is experiencing and talking about is this discrepancy between what pain is and what we're told pain is and the hopelessness is real but there are so many ways to change the pain recipe so pain is obviously an important signal from the body as you said it's the body's warning signal but we received an interesting note from a listener named Zara she knew something was going on with her body but was not in

1:10:29major pain then a routine blood workup showed abnormal results she was eventually diagnosed with a condition called endometriosis still doctors dismissed her because she wasn't in severe pain and I had to fight just to get an MRI and when I did it showed extensive regrowth and I ended up having another surgery and losing my left ovary so now I am six months post-op I still feel my left ovary when I ovulate even though it's not there

1:10:59anymore I think it's phantom pain and my brain still has a map of something that no longer exists so your episode really made me wonder about how often pain and the absence of pain leads us to misunderstand what's happening in our own bodies my body was telling me something for years even though it wasn't what medical experts expected me to feel or believe what do you think Rachel what a beautiful

1:11:30example from Zara in our last conversation together we talked about the difference between pain and damage or the difference between hurt and harm and I like putting those words together to remind everyone that hurt or pain and damage or harm are not the same thing there are a lot of examples

1:12:00of this throughout the medical literature throughout the research and of course in clinical studies like the example that Zara gave us and can I tell you a story that exemplifies this so about 30 years ago there was a little boy growing up in Jamaica and he was really fast and he loved to run and it was his dream to one day be in the Olympics but as he grew something strange was happening to his spine it started twisting into

1:12:30an S shape and the older he got the more his spine twisted and twisted but it didn't stop him he had very little pain he kept running he was eventually diagnosed with a very real condition called scoliosis which of course is when your spine twists into an S shape it didn't stop him he continued to train until he made it to the Olympics and by the time he made it to the Olympics his spine was so damaged and so abnormal

1:13:00and his body was so asymmetrical that his right leg was half an inch shorter than his left it did not stop him he competed in the Olympics this man won not one gold medal but eight do you want to guess the name of this gentleman it can't be Usain Bolt can it oh my friend that man is Usain Bolt he is the fastest man alive now

1:13:32why is this story so important if damage and the abnormalities found on scans were the cause of pain Usain Bolt should be disabled and relegated to a hospital bed he should not be faster than a bolt of lightning and this is a good reminder that hurt and harm pain and damage are not the same thing that's part of that's one of the lies we have all been told and sold

1:14:02and as long as you believe that the damage to your body is the sole cause of pain you will continue to have surgery after surgery after surgery you will forever take pain medications and by the way surgeries and medications can be life saving no shame in this game but they are not the only solution for chronic pain and research says they aren't the best solution and this is also true by the way as Zara noted for endometriosis which is a very real and important women's chronic

1:14:33pain disease but what we know about endometriosis if you look at the research you will see that endometrial overgrowth tissue overgrowth is unrelated to how much pain a woman has some women have significant overgrowth and no pain others have very little growth and a ton of pain so the takeaway here is that pain is more than just tissue damage

1:15:04pain is always bigger and wider and deeper than just that so it strikes me in listening to several of these listener stories Rachel that treating pain is just really tricky in some cases medical interventions focused on specific biological markers work in others they don't work sometimes it's helpful to listen to pain other times like with phantom limb syndrome the pain in some ways is misleading us so I have a lot of compassion for people who

1:15:37serious harms that come from under treating pain but as we've all seen with the opioid epidemic there are also serious harms that can come from over medicating pain this whole field is just not easy is it oh you got it chronic pain is extremely complex and this goes back to that thing where health care providers want to understand pain but we aren't getting sufficient or adequate pain education and what

1:16:07pain then don't understand pain because our health care providers are sold this myth that pain is a purely biomedical phenomenon and what's really challenging and frightening frankly about that is that when I think about quote unquote pain patients we are talking about every single one of us like tell me a human being that's going to escape the experience of pain pain is ubiquitous and it is coming for all of us one day if it

1:16:38hasn't already whether it's childbirth or an illness or inhabiting an aging body so it couldn't be more important for all of us to understand the science of pain when

Coping Strategies for Chronic Pain

1:16:52we come back more ideas about coping with chronic aches you're listening to Hidden Brain I'm Shankar Vedanta

1:17:07this this is hidden brain I'm Shankar Vedantam Rachel Zofnes is a psychologist at the University of California San Francisco School of Medicine she's the author of Tell Me Where It Hurts the new science of pain and how to heal Rachel many people who experience chronic pain respond understandably by limiting movement in the part of the body that hurts you say that an important aspect of pain treatment is to begin to move the body again gently but consistently why would this

1:17:37help right one of the most important fundamental tools for recovering from chronic pain is a tool called pacing and pacing for pain is much like pacing for a marathon so Shankar if you said to me you know Rachel I really want to run a marathon I would say that's cool Shankar I don't want to but if you want to I don't recommend that you start by running 26 miles tomorrow and you would not do that if you wanted to run a marathon you would pace yourself and

1:18:08what that means is you would start by walking and you would mix in some jogging and you would mix in some running and eventually over time your brain and your body would adapt and adjust and you would get stronger and eventually you would be able to run 26 miles so when we pace for pain what we're actually doing is taking our power back because chronic pain is a thief it steals from us our ability to work and to

1:18:38exercise and to play sports and you know to roll around with our young kids on the floor or our grandkids and even to

1:18:48for pain is one of these strategies where we pick a beloved hobby or activity that pain has taken from us and that's one of the first questions I ask my patients is tell me an activity that you used to love that pain has taken from you and some of your listeners in their questions have even talked about some of these activities so for some of my patients that's soccer for another it was Irish dance and for another it was fudge making you know and so we pick

1:19:19one of the activities that we miss that we used to love and we put together a pacing protocol which is in part three of tell me where it hurts so anyone can do this and you what you do is we want to see how much you can do on a bad pain day when pain is really high a lot of people can't do any activity so they're at zero and then we want to look at how much you can do on a day with very little pain and then we find your baseline we calculate the baseline amount of activity you can engage in and

1:19:49we slowly gradually work our way up from our baseline until we achieve our goal until we're running that

1:20:04adapt and adjust and get stronger slowly over time until we are re-engaged with the world both physically and emotionally and socially listener Jean wrote in with a story about using a gratitude meditation to help with pain after a horseback riding fall it left her with a severe cervical spinal cord injury she writes before the fall I was working as an occupational therapist I had worked with many patients with severe

1:20:34injuries I knew I had to do more than take pain meds and wait to get better I walked daily first with a companion and eventually alone for about 30 days I did a daily guided meditation on gratitude that I found online this helped me look at the positive things in my life not just doom scrolling I watched only upbeat and comedic movies and shows I read only positive literature I surrounded myself with people who were encouraging I kept a bit of distance for a while from friends who were discouraging

1:21:05or negative all of these activities I had seen my patients do that had the most positive outcomes it took me about three years to recover with some lingering limitations I was able to return to work part time and resume driving about three months after my surgery driving was a big goal for me because it meant that I had greatly reduced my pain meds and could drive safely what do you think of Jean's technique for reducing her pain Rachel Jean's story really strikes me because it seems like mindset shouldn't matter like

1:21:35the thoughts we think affect our bodies that doesn't make any sense at all why would it affect our pain and it goes back to what we were talking about before where there's this persistent myth and stigma that pain is all in our heads and of course I want to say clearly pain is never all in our heads it's biopsychosocial always however 70% of studies on pain and optimism show there is a connection between hopeful thoughts and reductions

1:22:06in not just pain intensity but also frequency and disability so for me the question was why and here's the answer thoughts don't just occur in the space between our ears every thought we think triggers a neuro biological cascade in the human body and it affects our neurotransmitters our hormones our immune cells even our cardiovascular and our musculoskeletal systems like the thoughts we think

1:22:36do not just live in our heads there's a trickle down effect that affects our bodies so what we have seen in the pain literature is that an optimistic and hopeful mindset can boost feel-good neurotransmitters like dopamine and serotonin and endorphins which again are our homemade opioids which reduce pain it it it it can also reduce our risk of health conditions like cardiovascular disease and crazier

1:23:06it can even increase our lifespan so it is true that optimistic and hopeful thoughts can change our bodies and change our pain but I want to say very clearly that this is not the same as toxic positivity like I hate that and a lot of my patients do too toxic positivity in my opinion has no place in medicine so we're not saying you know just cheer up and be happy and hopeful all the time that isn't realistic pain is depressing pain is scary pain

1:23:38is enraging pain stops us in our tracks and prevents us from engaging in beloved hobbies so I think the solution is yes we should feel all of our authentic organic feelings and we should feel hopeful that pain can change and that's what we're saying here today that's the most important take home message is that the brain is always changing and pain is always changing and that means pain can change hmm

1:24:08we heard from a number of listeners who talked about using distraction to reduce their pain levels here's one of those messages from listener Carolyn when the pain surfaces I unknowingly until I heard your recent program apply what I call my pain disappearance recipe I bring my dog to the park to play with other dogs which makes me laugh and feel joy

1:24:38or perhaps a friend of mine who fishes a lot catches four rainbow trout and gifts them to me and I'll throw an impromptu dinner party with friends of trout almondine and perhaps I'll bake a peach crumble for dessert with the peaches I got from the farmer's market which I frequent twice weekly or more importantly I'll find someone maybe

1:25:09a neighbor maybe someone from church who is in need and help them and before I know it my pain is gone Carolyn is describing what I would like to call the perfect pain recipe and what Carolyn is doing so beautifully is she's taking control of all of these different ingredients to change her pain experience and she described a number of activities that boost her mood

1:25:40and distract her brain and offer her some social support and get her body moving so circulation is better her muscles are engaging endorphins are increasing in her brain serotonin and dopamine are going up she talked about baking and going to dog parks and using the power of distraction and volunteering doing kind things for people and I just really loved how she's using this concept of a pain recipe to change the experience she's having with her body so

1:26:12it strikes me that distraction might be a particularly difficult technique for a clinician to suggest imagine telling a patient in pain just think about all the good things in your life and try to be of service to others it can feel like you're suggesting the pain is all in their heads and

1:26:35recommend some of these interventions without coming across as callous or uncaring one of the most important pieces of information I share with health care providers like I provide pain education around the globe I do grand rounds at hospitals for doctors I teach at Stanford and UCSF and one of the concepts or metaphors I like to teach the most is this concept of a pain dial so if you imagine in your central nervous system which is your brain and your spinal cord that you have a pain dial that operates much

1:27:06like the volume knob on your car stereo many things turn pain volume up many things turn pain volume down one of the things that turns pain volume up is focusing on pain talking about pain and thinking about pain we know that our prefrontal cortex the front most part of our brain operates much like a magnifier and when we pay attention to a certain body part the magnifier

1:27:36zooms in so if I tell you right now Shankar sense into your left foot and notice your foot on the floor and feel your sock on your skin all of a sudden your brain magnifier is zooming in before you weren't paying attention to it who cares about your left foot now

1:27:58what's cool about this pain dial is that the opposite is also true when we distract we focus on other body parts we engage with the world we volunteer we bring our dog to the dog park you know we get a massage what's happening is that the prefrontal cortex is now zooming out it's zooming away from the painful body part and it's lowering pain volume in the brain so the

1:28:28strategies like this is just by front loading with neuroscience because it makes sense and we've all had these experiences and once you understand the science of how the brain works the stigma is gone as soon as you know that your brain has a pain dial and you know that you can put your hand on that dial to lower pain volume all of a sudden you take your power back from pain and that is the most incredible experience it gives people living with pain hope and

1:29:00hope is an important ingredient for healing Rachel Zofnes is a psychologist at the University of California San Francisco School of Medicine she is the author of Tell Me Where It Hurts The New Science of Pain and How to Heal Rachel thank you so much for joining me today to answer listener questions thank you for your great podcast and for disseminating great science

1:29:31we also heard today from University of Washington sleep researcher Chris Barnes problems like sleep deprivation and chronic pain can have profound implications for our physical and mental health if today's conversations were useful to you you can find more resources on these topics on our website hiddenbrain.org and if there are other people you know who might benefit from these ideas please share this episode with them

1:30:01hiddenbrain is produced by hiddenbrain media our audio production team includes Annie Murphy Paul Kristen Wong Laura Querell Ryan Katz Andrew Chadwick and Nick Woodbury Tara Boyle is our executive producer I'm hiddenbrain's executive editor I'm Shankar Vedantam see you soon

1:30:30liked you like your your dog laugh you you you you you you you you you