It’s All in Your Head?

The Song of Our Scars
By Haider Warraich
New York, NY, Basic Books

Recently, I was driving in the massive Texas sun to the Austin YMCA, settling into the middle of a radio interview with some guy who clearly knew a lot about pain. I go to the Y every day because swimming laps staves off the trickster jabs of sciatica that would otherwise dominate my day. As the radio guy was discussing the power of placebos, I was pulling into a parking space next to a thick and weedy slough filled with a stand of irrepressibly purple spiderwort, not at all intimidated by the unremitting sun.

I already knew that a “fake” pill can be just as or more effective than a “real” pill when they test the efficacy of new drugs. But get this: a placebo, a fake pill, retains much or even more of its power even when patients know they’re taking a placebo. What special mojo is that? It turns out that the secret ingredient in a good placebo is the care and attention of the treating doctor—or acupuncturist or anesthesiologist or physical therapist or nurse practitioner or mother. That caring, empathic person, I’d add, might be a psychotherapist seeing a client who’s stuck in a labyrinth with the life-eating Minotaur of chronic pain. Psychotherapists, not surprisingly, will have a crucial role in our growing knowledge of the psychology of chronic pain.

The guy on the radio was Haider Warraich, a physician educated in his native Pakistan. Trained as a cardiologist at Duke, he now teaches and practices in Boston. In the interview, he was saying that our bodies have their own irrepressible ways to manage pain. As I’d later read in his new book, The Song of Our Scars: The Untold Story of Pain, “our innate ability to endure pain is so immense that it may well be a superpower.” That superpower can be summoned with the bat signal of the placebo.

In The Song of Our Scars, we get clarifying tracts explaining not only how pain happens, and how physical sensations morph into the felt recognition of pain, but also about how even—or especially—clinicians misread the shape-shifting spell of chronic pain. Warraich would know well: in the middle of medical school, he was felled by a gym accident, damaging his back so severely that he struggled through his residency with debilitating pain.

Pain is at the center of life, Warraich writes, and is forever hitched with the bare fact of being alive, where “nothing is as important to our ability to survive as our ability to hurt.” We stub our toes, get bit by bugs, get knocked in the head; we deal with cranky knees and troublesome stomachs, and worse. Whether it’s an ouch or an itch, these are all nociceptive sensations: a response to a noxious physical stimulus from a real and impinging world. It’s the brain that interprets this sensation, giving meaning to what we sense. In the case of nociception, Warraich writes, we have a bottom-up system of perception. If the brain pays attention to it, it goes on to interpret whether something is a threat or, say, an annoyance: was that a dangerous bee or a poking twig? The actual experience of pain, what it feels like, takes place in the brain, and sometimes, we can be so intensely involved in something, our minds distracted, that we only discover later that we’re hurting. Not everything reaches our consciousness. No brain, no pain, you might say.

Indeed, the experience of pain, a “hallmark of consciousness,” is said to be this integration of stimulus and interpretation. In acute pain, when we bloody a knee, the body’s natural capacities for repair usually save the day. Along the way, as the body’s immune system is stimulated, inflammation might develop, and maybe the nociceptive penumbra of disturbance expands: a fever, an overwhelming sense of fatigue. But these secondary reactions resolve themselves as the wily immune system completes its task. Chronic pain, however, behaves contrarily from our highly adaptive nociceptive pain systems. And here we arrive at the “untold” story of pain in the subtitle to Warraich’s book.

Chronic pain is rarely acute pain prolonged. Rather, the original systemic flow of painful signal and helpful response goes haywire. Long story short: pain, Warraich writes, “begets more pain.” For one thing, with ongoing stimulations and continual disruptions, the nervous system has trouble staying in balance: it maladapts such that more noxious sensations beget yet more exquisitely sensitive nerves—what’s come to be called central sensitization. It’s not at all, Warraich writes, that what doesn’t kill you makes you stronger; instead, “the more one hurts, the more sensitive one becomes.” It’s for this reason that with acute pain, an early regimen of painkillers helps tamp down the ballooning sensitivity and facilitates healing.

Central sensitization, a neuropathic phenomenon, is a top-down pain—namely, the brain is recreating the felt experience of pain without any new signals asking it to do so. To be sure, some neuropathic pain comes from damaged nerves, whose bottom-up ascending signals bombard the brain. But central sensitization has no or few ascending signals: it feels like there’s active tissue damage going on, although it’s not so. Like a bad song stuck in our head—the song of our scars?—the felt experience of pain takes over, endlessly repeating. How come?

When researchers used fMRI scans to compare patients with pain, they saw that the circuits of acute vs. chronic pain appeared to light up two separate and distinct areas in the brain. And in patients whose bodies were actively shifting from experiencing acute pain into persistent chronic pain, the researchers could observe how the localization in the patients’ brains shifted from parts of the brain involved in sensations over to circuits primarily regulating emotions. Evidently, in comparison to acute pain, chronic pain involves the emotive parts of the brain. But despite or because of that difference, “our brains do not habituate to chronic pain,” Warraich writes, and instead we experience it as acute pain, something wrong that needs to be fixed.

As there’s no single working theory about what’s functional with chronic pain, Warraich wants to understand to what extent chronic pain functions like a difficult emotion—a negative affective state that organizes behavior and is social in nature. But ultimately, Warraich questions whether chronic pain is “something else altogether: a memory.” In fact, one neuroscientist he cites is researching whether the real root of chronic pain is our body’s insistent remembrance of it, its indelible imprint on our hippocampus. As Warraich quotes him, “Painful stimuli are the most effective means to develop memory.”

It’s dazzling to imagine how the body’s blunt efforts to remember, an effort bypassing language and intent, might underlie the power of chronic pain. Perhaps the phenomenon of chronic pain—in particular, noncancer chronic pain—is not so much a warning signal for an ongoing injury, but the body’s effort to attend to an outdated threat. Having read physician John Sarno’s insights on the psychological underpinnings of some pain, I wonder, if chronic pain is a signaling problem, a body and mind tuned to a threat that’s no longer there, does it then begin to function much like traumatic memory?

The amelioration of chronic pain depends not so much on how specific parts of the body are managed, but on how larger, subtler yet powerful systems in the body/mind/culture are managed. Warraich argues that modern medicine has “medicalized” chronic pain, and you’d think, well, sure. But his point is that by flattening pain into a physical sensation, we’re ignoring other powerful aspects that shape and augment the experience of pain. He warns that pain is sensitive to context in a way no other human sensation is. Class, race, gender, social isolation, religious ideas of suffering, money—all are factors in whether your pain is recognized, whether you’re deemed worthy of care, whether your suffering is something real or a reflection of your poor character.

Pain is a social phenomenon, a communication not only within oneself but to others. Not surprisingly, research shows that when most chronic pain persists, its intensity is reduced when we’re part of a trustworthy culture that recognizes our experience and helps us. This question of trustworthiness has a central place in our healing. One example of many: research with Black patients demonstrates that pain sensations diminish significantly when in the care of a Black doctor and Black caregivers.

If what’s necessary for the care of chronic pain hangs on the objectivity and decency of the American healthcare system, we’ll end up royally, er, screwed. In the deep argument of this book, Warraich wrestles with how a profound misunderstanding of chronic pain and a blatant disinformation campaign has been at the hot center of one of American medicine’s most obscene and unforgivable chapters: the sorry sight of doctors and lobbyists abetting the pharmaceutical industry in a willful blindness.

That story pivots around this modern secularization of pain, how our society has narrowed its understanding of pain “to fit the constraints of the tools and rituals of medicine.” Our dream of a lifetime free of pain and suffering has been fed by a biomedical and pharmaceutical industry that promises a false liberation from ordinary processes of decay and sorrow. This wish for “mass anesthesia” will not be tempered as long as American medicine in particular is captured by a corporate zeal that transforms “people into consumers, transmuting human suffering into a lucrative opportunity to maximize profit.”

And so we come to the scourge, the bullwhip, the blacksnake, the bitter pill: opioid drugs. When Warraich was a young doctor, far from Pakistan, working in American emergency rooms, the use of opioid drugs “marked every day of my internship.” Doctors and nurses were trained that the best way to help people in pain was to prescribe opioids—prescription after prescription. But, perversely, at the same time, “we were overwhelmed with patients suffering adverse effects of opioids.” So much so that he and his fellow residents were shocked by a recent graduate’s account of emergency treatment in hospitals in Switzerland: there for six months, he’d not prescribed a single opioid. The rates for chronic pain were the same as in the U.S., but the Swiss doctors were trained differently.

So began Warraich’s literacy in the miseducation of American doctors, or “drug mules in white coats,” as someone calls them. As it turns out, opioid drugs are useful for acute pain—a short course after surgery, for example, but they’re not a panacea for chronic pain; rather, they are . . . its engine.

The body has a natural system of pain regulation, the superpower that is our own opioids. Natural opioids, our beta-endorphins, work by “slamming the door on painful nociceptive signals attempting to ascend the nervous system toward the brain.” These beta-endorphins are linked to our stress-response system and moderate how quickly we recover from extreme stress. They also facilitate feelings of connection and belonging. Chronic stress causes us to produce more natural endorphins than usual, inducing a natural beta-endorphin dependence, which makes us more sensitive to “everyday nags and nicks. An ache that might never even be registered by the person at peace might crush the person under duress.”

You’d think that opioid medications would be helpful here, that they’d bring about yet more relief for chronic stress or for chronic pain. But these drugs don’t help: “they are simply too blunt and too powerful, rocking the delicate balance of the body’s natural pain-regulation systems.” In fact, because opioids hijack the natural system, they “actually reduce the user’s pain tolerance, so the patient’s chronic pain worsens.” Even a small dose of a drug like morphine or oxycodone dwarfs the amount of beta-endorphin our body can produce by itself.

The result is that opioid medications have little efficacy beyond ordinary pain relievers or even the famous placebo. When the brain is no longer receiving nociceptive signals but instead is manufacturing the pain signals itself, as happens in most chronic pain, long-term opioid medications won’t work. The research is devastating: “One recent randomized trial showed pain intensity was worse in U.S. veterans using opioids for moderate to severe chronic back and joint pain than in those using medications like acetaminophen and ibuprofen.” Over time, the experience of pain actually increases, meaning people on opioids for extended periods become convinced they need more and more of the medication while, sadly, they’re getting less and less benefit, are more sensitive to pain, and are often on the brink of overdose. So why did doctors continue to prescribe them? It is, Warraich writes, the “worst medical mistake of all time,” based on the fatal combination of greed and an ignorance of the special characteristics of chronic pain.

Warraich argues that pharmaceutical companies have plotted and planned and transformed modern ideas about pain into a myth that it’s entirely and perfectly controllable. In particular, at Purdue Pharma, Arthur Sackler, one of the original Sackler family owners of Purdue, schemed not so much to ensure that the powerful opioid drug OxyContin was in fact safe, but that it was perceived as safe. After 25 years of mismanagement of opioid drugs, the results were and continue to be disastrous. Even as recently as 2021, despite doctors’ attempts, skillful or not, to limit prescriptions, 71,000 people died that year from synthetic opioids.

If not drugs, what’s for treatment? People in chronic pain often feel disrespected, if not ignored, when a helping person, correctly or incorrectly, suggests that there might be something other than a definable physical cause at play. Going into the tunnel of an MRI machine “almost every patient with chronic pain hopes something will light up,” Warraich writes, “that something broken will be found. The last thing they want to be told is that everything looks good.”

Everything looking good foretells yet more of the grim search, the grinding medical whodunit, for a diagnosis and, hopefully, a cure. Likely the patient will be thrown back into a regressive healthcare system with few avenues of care. Labeled malingerers or crybabies, people with chronic pain often endure suspicions from their friends and partners—even from their own doctors! Actually, that last sentence doesn’t deserve an exclamation point. If you’re a woman or LGBTQ or a Black person or a poor person, you know well how disbelieving most medical professionals can be, inferring, It’s all in your head.

The fact is, all pain is in our head, but dredging up the dreaded “psychosomatic” label doesn’t mean that chronic pain isn’t real. The pain is real, but a big part of its treatment is behavioral and psychological. If we aim to retire the patronizing snark around notions of the psychosomatic, we must honor the unity of body–mind divisions. Beyond some entangled dyad, let’s recognize it as an unstable union of several already-enmeshed systems: nerves and gut biomes, brains and hearts, immune systems and context-determined emotions—all a package deal by the time we’re born, all interacting with and working on and talking to each other.

If psychosomatic only refers to a mental condition masquerading as a physical condition—well, that happens too. I myself was cured of a terrible year-long back pain by reading John Sarno’s admonitions to investigate emotional events around the onset of back pains. Surprisingly, that worked. Several years later, with a second attack of back troubles, I labored to figure out what psychological difficulties were extracting their heavy tax, but in the end, it was a physical condition that was resolved with knee surgery and plenty of physical rehab. I say “resolved,” but for the chronic pain of it I needed, and still need, a crackerjack physical therapist, many kindnesses from doctors and the people around me, a course of antidepressants, a meditation practice, and a fairly rigid exercise schedule that itself needs constant pep-talking. To this end, there are not only the purple spiderworts in the Y parking lot to cheer me on, but the wild and arm-waving helianthus, the mistflower, the pink primrose, and if I’m lucky, the spotted beebalm.

What relief is there for people with centrally sensitized chronic pain? What I understand—from Warraich’s writing, from others, from my own personal experience—is that mitigation requires a multidisciplined approach: a carefully monitored, step by step, often counterintuitive engagement with motion and other physical activities, despite fears of injury. It involves managing the anxieties and depression that encase the sufferer, hardening her into a constricted self she barely recognizes. She needs community support, including occupational therapists, friends, family members.

I’d say that psychotherapists could well address many of the personal and interpersonal muddles that arise: the issues of identity in the face of increasing helplessness as the experience of chronic pain becomes entwined with feelings of unworthiness, thoughts of being victimized or punished, of loss of faith in one’s own body and the goodness of the world. The Song of Our Scars will be essential when you encounter, as you surely well, clients experiencing chronic pain, bringing the opportunity for you to be one of those caring, trustworthy people, as vital as the potentiating placebo.