Dr Rupy: An equation is essentially anything that increases safety, increases cues of safety to your brain over the long run can reduce pain, anything that increases cues of threat increases pain.
Dr Rupy: Welcome to the Doctor's Kitchen podcast. The show about food, lifestyle, medicine and how to improve your health today. I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests while we discuss the multiple determinants of what allows you to lead your best life.
Dr Rupy: We need to revolutionise our understanding of pain. Most of us hold on to this false belief that pain is a measure of tissue damage and the two are correlated linearly, a detector of physical injury if you will. But I'm speaking to Dr Monty Lyman who argues that pain is a protector rather than a detector. Dr Monty Lyman is a medical doctor and research fellow at the University of Oxford and his first book, The Remarkable Life of Skin, was shortlisted for the 2019 Royal Society Science Book Prize and was Radio 4's Book of the Week and a Sunday Times Book of the Year. Today, Monty and I discuss what pain really is, his personal journey of dealing with pain from IBS, how hypnotherapy and homeopathy might work to reduce pain even if you don't believe in that, why loneliness and lack of community can lead to pain, the concept of neuroplasticity and its relationship to pain as well as movement, visualisation and how pain education can help reduce and rewire our relationship with painful stimuli. In this new piece of work, The Painful Truth, honestly, he beautifully presents a collection of patient stories, personal experiences and importantly, the evidence base for a more nuanced understanding of pain and I highly recommend it as a read. You can find that on the podcast show notes. I'm doing a new thing which is our podcast recipe of the week that relates to the topic of conversation on this week's podcast. Inflammation is a huge, huge issue when it comes to pain. We actually talk about that at the end. And if you're interested in more about an anti-inflammatory diet and why that relates to pain, you should also listen to an episode that I did with Dr Deepak Ravindran all about pain and the seven ways in which you can improve your relationship with it. I'm choosing the green bean salad that you can find on the app. The link to which is in the show notes, iPhone only, Android users, please bear with me. I am definitely working on an Android version. And you can check it out if you don't have the app on this week's newsletter, Eat, Listen, Read. Just head to thedoctorskitchen.com and not only do I send you a recipe to cook every week, but also some mindfully curated content. It might be something to listen to, something to read, something to watch, something that will help you lead a healthier and happier week. The response has been brilliant from it. I'm really proud of that newsletter and I try and read all the feedback as much as I can. Anyway, I'm going to stop waffling on. This is my wonderful, wonderful conversation with Dr Monty. I'm sure you're going to absolutely love it.
Dr Rupy: I've read this one, as you can tell. I got the early copy and I just, I remember, yeah, it's well-leafed. I remember just like taking, like folding so many pages that I need to look into this. This is absolutely fascinating. But I wanted to start actually by asking you about how you got into writing in itself because you write so well and I wonder if this is a skill that's something that that's something that you you developed early on or you know, where did this love of writing come from?
Dr Monty Lyman: Yeah, that's a that's a good question. I think I when I was at school, I didn't know whether I wanted to do medicine or science or or do something where I do more writing, something I loved philosophy, I loved history, I loved literature. But there was this moment in one of my biology classes, I had a great biology teacher where he got us to write an essay on, I think the essay title was, are viruses alive? And it really got me into sort of understanding that there is deep sort of philosophy, deep richness to biology, the natural world, the human body. And then I decided to go down the medicine route and hoping that maybe I could be doing some writing along the side. I never thought I'd end up writing writing books. And I think that my latest book on pain, it wasn't even a book. During medical school, I wasn't that interested in pain. Pain was a sort of a a symptom of more interesting diseases, I thought. But actually there are a number of episodes in my career as a a junior doctor that made me realise actually, I think we've completely misunderstood pain. And I wanted to communicate that to people and that for me that's most I most naturally do that through through writing, sort of the long form. So I I started to getting a manuscript together for that.
Dr Rupy: Yeah, yeah. And we've spoken to Dr Deepak Ravindran who I I understand you know as well. You've written about in your final chapter. Yeah. He he he's an amazing chap. I wonder just to anchor the listener, we could go into exactly what we mean by pain. I know we've discussed this before, but I think for this, this is particularly pertinent because it frames everything else that we're going to be talking about that you've eloquently written in the book. So what do we mean by pain?
Dr Monty Lyman: I mean, there are lots of different definitions of trying to get to what pain is. People often when I was when I told people I was writing about pain, they said, oh, you're going to be talking about sort of, you know, emotional pain and things like that. I'm just focusing on what we sort of so we tend to term sort of physical pain, quote unquote, but actually pain is simply a horrible feeling in our body that urges us to protect a body part. That's all pain is. That's the core of what pain is. And it can be short term, which is known as acute pain, but it can also persist for months and years and decades. And that's traditionally been termed chronic pain. I and lots of other people in the area prefer to call it persistent pain because chronic sort of a lot of people don't really know what it means and it can it can be quite a defeating word to a lot of people as well. So I think persistent pain is I prefer to use that. But yeah, acute pain is a short term pain and and chronic pain are very different beasts.
Dr Rupy: Yeah, yeah. And you talk about this concept of injury not being necessary nor sufficient for pain. And I wonder if we could sort of dive into that a bit more because most people when they come across pain, it's in the physical sense and it's a response to a physical mechanism, but that's not necessarily the case.
Dr Monty Lyman: Yeah, and that was the just the amazing discovery that well, it wasn't my discovery, but when I realised it as a junior doctor and I looked at the research, it was just amazing that most of us completely misunderstand pain. And by most of us, I mean lots of people in the medical field as well. We sort of we quite understandably assume that pain is an accurate measure of tissue damage, that there are sort of pain receptors and pain pathways that go to your brain like sort of ringing a bell. So you pull the end of a rope and then a bell rings at the end. And for a lot of short term pain, you know, that makes sense. You know, you slam your your thumb in your laptop, it hurts a little bit. You slam it in a car door, it hurts a lot more. But actually the relationship between injury and pain in chronic pain, persistent pain, long term pain is is not so clear cut. And actually many, many cases, perhaps the majority of cases of persistent pain, pain that's lasted beyond the time that the wound should usually heal. So that's often sort of three to six months, it varies. Pain that goes on for years, often whatever caused the initial injury has completely healed or has mostly healed, but pain has become wired in the brain. And the critical thing is, you know, I'm not saying it's all in your head, it's it's become wired in the brain. It's neurological. It's, you know, as real as as epilepsy. But that means that the the whole approach to it is is completely different. If I can, basically there's a there's a a story, a patient that I saw in my first year as a as a junior doctor that I'd like to like to share. This is the sort of the moment that I realised that this isn't just an academic misunderstanding, it affects the lives of of millions of people. So I was in my first year as a as a junior doctor, I've changed some of the details, but but basically I was on a an acute medical unit. So basically it was this the step. So if you go to A&E with a problem, you'll then sent to either an acute medical unit if you've got a medical problem or a surgical unit if you've got a surgical problem and other other units potentially. And what we do is we go and see all the different the patients who've been who've come to us from A&E and I would sort of chase after the consultant with a sort of a a pile of notes, like currently like scribbling what he was saying very quickly and seeing the patients and deciding whether they need to go to another ward and stay in the hospital or whether they could be discharged home. And there was a patient, let's call him Paul, who was an IT worker in his mid 40s, who had terrible, terrible back pain and he'd had it for over six months. It started in a sort of lower lower left side of his back and it progressively got worse over six months. It got worse in intensity, it had become constant and it had spread across his back. And because of that, basically he'd lost his job and he was over the last couple of weeks, he was going through a divorce essentially, partly related to the pain. And that morning, he was in so much pain, he couldn't get out of bed, ended up calling an ambulance, went to A&E. And for various reasons, the doctors wanted to sort of rule out all of the causes of the back pain. So he had loads of blood tests, an MRI scan, and all the results came back completely normal. So then when I came to this patient with the consultant, the consultant looked at looked at the computer, looked at the the notes and said to Paul, the good thing is there's nothing physically wrong with you. And then Paul, who was still clutching his lower back, beads of sweat running down his face, said, are you saying it's all in my head then? I can't quite remember what the consultant said, but it was a really good consultant, but it was a bit of a bit of a fudge, I think. And the patient was sent home with some painkillers. And I sort of realised, I mean, looking back on it, I I realised that the patient was either thinking that the pain is in his body, so there's something that the doctors can't detect and there's some horrible thing going on that the doctors can't detect that's causing his pain, or it's sort of all in his head. So it's sort of some kind of thought disorder that he can just quite easily think away. And I think that's that's the problem because actually it's if it's become wired in his brain, if it's neurological, if it's physical and mental and completely real, there is a there is another way to address this. And I think sort of modern medicine has real difficulties with that.
Dr Rupy: Yeah. And and and this is really a spillover effect, I think, from the separation of mind and body that we've essentially been taught that that structure during med school. And I I wonder if we can dive into that example that you you gave there because I think this plays out in so many different scenarios across the healthcare system in this country and and others of of course as well, in many different ways because I think if you can't find that physical manifestation of pain, people feel either dismissed or that there's something that we've missed or something or the suggestion that this is psychological, ergo, you have a mental health problem, you need to focus on that and there's nothing that we can do. Whereas actually, I think what your your book and and the research now beautifully explains is that it's a it's almost like a continuum. It's like you can have that initial stressor that can be physical, but then that leads to other things like rewiring of the brain such that the pain is absolutely real. I mean, there's no way that the pain can't be real. If you've got beads of sweat going down your face and you're clutching your back as well, it's very, very real. But the way in which we treat it is has to be reimagined. It has to be changed.
Dr Monty Lyman: Completely. And I think one of the the ways in which persistent pain is tried to be treated by by doctors over the over the past half century and and beyond has been through painkillers and opioids for strong pain, which are miraculous in short term pain, but very rarely are the only solution in in long term pain and in most cases aren't the solution. That combined with various things has resulted in in the over prescription of opioids. I'm not saying that opioids shouldn't be prescribed because they can be very helpful, but there are there are there are other ways. I think understanding understanding what pain is is very important. So I think understanding that pain isn't a detector, it's not an accurate detector of tissue damage, but it's a it's a protector. It's a protective mechanism. So the brain is always trying to decide from inputs in the environment, from past experience and what it thinks is going to happen is is trying to basically is trying to protect us. And in many cases, it can become overprotective. So say you have that some kind of sort of injury in your back that heals, the brain is going to be very, very protective of of the spinal cord, even though it's incredibly, incredibly tough. A combination of the the signals if the pain persists can become sort of it's called central sensitization. Basically the brain it becomes sensitized so that any kind of signal, even if it's not a a danger signal, can start to cause pain and it gets worse and it can stay stay longer. And the brain essentially becomes rewired. And then negative thoughts associated with that, beliefs that your your back is crumbling, just the very the very thought of that, even sometimes seeing MRI scans, which I'll go on to in a second, they don't actually often show very much, can make pain worse and can can make people go down this horrible, horrible spiral. And I think with MRI scans of of of backs, there have been lots of studies where they've done MRI scans of people who have no pain at all. And roughly 20% of 40% of 20 year olds and almost all 80 year olds have some signs of sort of disc degeneration, no pain at all. And also things like elements of what looks like a slip disc and things like that are very common in people without any pain. And often these these are sort of medically as important as wrinkles. Obviously there are more serious sort of back damage that can cause pain in the long run. That's key. And and another important thing that I I need to make clear is that the receptors that um say in our in our skin that say if you you burn your finger that transmit a signal to your brain and then pain is created, that's actually not necessarily a pain signal. So it's it's called nociception, which is essentially danger detection. So they're danger signals. Your essentially your unconscious brain has to decide whether these danger signals are worth causing pain. And these these signals are neither necessary nor sufficient for causing pain. So there is some some quite sort of in the pain field, some quite well known examples of sort of pain being caused without injury and and the opposite. So for example, so just to give some clear examples of why, you know, injury isn't isn't pain. Um there's a there's a case study and there are some other case studies like this of a a British builder in the about 20 years ago or so who was climbing down his the scaffolding from a building, decides to jump the last few meters, landed on a a wooden plank, but it was a wooden plank with a sort of I think it was a 15 inch or maybe a bit smaller nail sticking out of it and it went straight through his boot through one side and out the other side. He was in absolute agony. Um went to to A&E, ended up having fentanyl, which is a very, very powerful opioid, more powerful than morphine, and he had some sedative as well. He was just in absolute agony. The the surgeons very carefully cut the boot off to reveal that the nail had gone between his toes and hadn't damaged any skin whatsoever. And then you've got cases of so the the brain very understandably had predicted that the foot was in damage or the foot was in danger or damaged and created pain. And there have been lots of there have been some other studies where um subjects have um had had sort of a a sort of a head stimulator put over their heads, but it's a it's a sham. And they were they were told that um they were going to have sort of currents delivered through the head stimulator that will cause headaches. And in most people, it did cause a headache even though there wasn't actually any current going through it. And then you've got cases of soldiers in the battlefield who are shot and don't feel the body has decided in that moment that pain is not as important as getting off the battlefield. So if you um if the bottom line is survival, in most cases, the body wants to be a pessimist. The body wants to create pain. Um but in very extreme cases, actually getting yourself off the battlefield is more important in the short term than actually than actually having pain. Um so I think it it boils down to understanding that it's a protect your your the brain is a a pain is a protector, not a detector. And then if you're thinking about treatment, the an equation is essentially anything that increases safety, increases cues of safety to your brain over the long run can reduce pain, anything that increases cues of of threat increases pain.
Dr Rupy: Yeah, yeah. And and this is that's a really good formula, I think, for us to stick with in our minds, I think, if anyone's listening to this because this comes to fruition in lots of different ways when you talk about society, loneliness, sense of purpose, all these different things that give us warmth and and security, um can dictate the levels of pain that we perceive. And I just wanted to go into uh one of those case studies. I think in the extreme example of the builder who expects that the nail has gone through the foot and therefore perceives quite, you know, literally there is a excruciating pain where actually there is no physical injury. That expectation, I think, is is is quite key and you you've actually dedicated a whole chapter to the expectation effect. And I I I don't know if you can remember, but because there's so many studies that you talk about in the book, but there was one that really stood out to me, which is about changing the brain through expectation and hope. And it was the wisdom tooth trial where they used fentanyl, naloxone and saline. Would you mind telling us a bit about that? Because I I found that like incredibly to to to read.
Dr Monty Lyman: I think, yeah, it's it's such an interesting area, the whole area of what's sort of traditionally termed sort of placebo effect and the opposite of it, which is the the nocebo effect. So if you think you're going to be in more more pain then you then you will. Um but as you as you as you rightly said, the expectation effect is a is a is a is a better is a better term. And I think this is so much relevance for all interactions between anyone, it could be it's not necessarily a doctor and a patient, it can be anyone and someone else who's in pain, basically. I think there's a huge responsibility for people who are um need to look out for people and help people who are in pain because it's hard to do these things on your own. So the the wisdom tooth study is really interesting and it shows how kind of fear and confidence are so contagious. So essentially there were um two groups of um dentists doing um a wisdom tooth um operation on on patients. One group of dentists were told that to sort of the the injection they were giving around around the wisdom tooth was either going to be um a a placebo or it was going to be um an opioid, um so of analgesic, so that they they knew that the patient will, you know, there's a 50 50% chance of the patient not being in pain. Um so 50% chance of the patient um having pain relief, 50% chance of it being a placebo. And then the other group was split into either um placebo or um so um basically naloxone, which is something that definitely blocks um you definitely like you won't have any pain relief with that because it blocks opioid receptors. Essentially the the the dentists who knew that there was a 50 50% chance of of having pain relief in the placebo section of their patients, they experienced um pain relief. But in the other half of the dentists in their placebo group, because the dentists knew and the dentists couldn't tell the patients anything, that's an important thing. Um in the placebo section of the other group where they were either getting placebo or definitely not pain relief, the placebo group experienced uh pain, like worsening pain. So what that what that means is essentially the the the um non-verbal cues, the kind of the confidence that the the dentists had knowing what they were potentially giving the patient was transmitted to the patient and the patient ended up experiencing more more pain, basically, even though they were having a placebo. Um and I think that's that's that is hugely important that in the in the fact that um clinicians really need to be so supportive and hopeful with patients. And I think a lot of um sort of psychological and sort of combined psychological and sort of functional therapies that are being used for um for persistent pain, um the ones that work have a combination, I think, of acceptance, being realistic about things and where you are at the moment, but also hope for the future and that things can change. And I think conveying hope, conveying um care, conveying love is is medicine in and of itself.
Dr Rupy: Absolutely. You know, this that particular example and that particular study really stood out to me as a clinician as well because those non-verbal cues, those little ways in which we describe things, the way we describe an x-ray, the way we describe a treatment, you know, all these things are literally having an effect. And I think this particular study should be discussed amongst junior clinicians in particular because it it really would stay with me throughout my career as to how I interact. You know, even taking the example of the consultant and the person who came in with back pain, for example. Um and and I think the reason why I wanted to talk about this is because I understand you've had your own experience with IBS, something that you you suffered with with with for for quite a while now, where you were given a uh a sugar pill essentially, a homeopathic treatment. And you know about how homeopathy has been debunked and you your skepticism was already there. So you weren't expecting any effect, but I'm I'm assuming the giver of said medication was a true believer of this pill. And that somehow has transferred. And I I'd wonder if you you'd share that story with us because I I thought that was super powerful.
Dr Monty Lyman: Oh yeah, this was sort of mind blowing for me at the time and more so looking back on it. I um so for um yeah, for as long as I can remember, I've had IBS, which is sort of ranged from sort of a bit of an irritation to like not being able to get off get out of bed, basically. Um which has been I've actually been basically almost been completely cured through sessions of hypnotherapy, which is another story. But when I was younger, I was having a particularly bad episode. I think it was a like a Sunday afternoon in a in a family home. I'm not going to make I'm not going to sort of mention who the person who gave me the homeopathic pill was, but it was someone, you know, someone a family member I I love dearly. Um who said, oh, you should take this this pill, like this homeopathic pill um for your for your IBS. And um you know, I I I was and homeopathy I remain skeptical about uh its claims. And I think just to sort of to to please them, I I took the pill. It was in this sort of packet with this sort of faux Latin name uh on it and it was this little what I assumed um and I still assume is a sugar pill and took it anyway. And my IBS was completely cured for at least for that day. And there have been some really so I think that's what you what you mentioned about the kind of the that that the transferring of that that hope and that love was a huge element of it. And there's also another whole new area of research which is emerging, which is um really interesting called sort of open label placebos. So honest placebos.
Dr Rupy: Yeah.
Dr Monty Lyman: Um so could you give people placebos telling them that it's a placebo, but through um various various sort of mechanisms, it can actually reduce pain. And there have been some studies that that show that it is it is quite effective in in things in say IBS is one example, but some other types of pain. I'm not at the moment suggesting that that's it's a good solution um to pain, but it might have it might have um roles in say, for example, if people are tapering off of something like opioids or um other medications, sort of interspersing it with honest placebos might might have have a role. The fact that it sort of works at all is quite interesting. And again, the the theories behind it, again, it's very, you know, how could a placebo work if you know that it's a placebo? Um perhaps an element of it is is our predictive brain. And a lot of the predictive brain is in areas of our brain associated with doing things, um and not just sort of thinking about things, not just the cognitive bit. So it's emotions, it's rituals, it's things like that. So actually the very process of just taking the pill, even if you have doubts about it working, can have some kind of healing process. The the extent of that it will we need to we need to find out, but it's it's it's really interesting. And I think it's sort of bolstering the theory that actually, you know, our our brains are a predictive machine and actually we can we can try and hack that in a sense to try and to try and help people with um persistent pain.
Dr Rupy: Yeah, I I you mentioned there hypnotherapy as well. And I and I wanted to to talk about this. I'm glad you mentioned that because I think there's an expectation that hypnotherapy works for people who are more suggestible than others and it's a particular person that would respond best to hypnotherapy. Um I wonder if you have any thoughts on that because you've experienced hypnotherapy yourself. I think it's one of the things that has led to to healing in your case. Um and and I I guess this ties into the emotional brain and how that can be used and harnessed to to reduce pain overall, back pain as well.
Dr Monty Lyman: Yeah, yeah, definitely. Um so and that's a that's a really interesting question about sort of susceptibility to to um hypnotherapy. I don't see hypnotherapy. And I think there's a lot of debate debate in that area. But so basically I was researching the book um a couple of years ago um and went to I saw that basically I I I've researched basically any kind of cure for my my my my IBS. And often it's in many, many cases, it's it's mainly dietary, which is a cause of it, but in many cases, it's often it's a case of both. It's it's the brain and and the gut, but they're so interlinked and the gut affects the brain massively and the brain also affects the gut. But in my it seemed to predominantly be related to stressful events. Um and yes, so I I went to this hypnotherapist not not to have any hypnotherapy myself, but to interview him about hypnotherapy for the book. And he said, oh, what do you do you have do you have any any sort of um pain issues, pain or anything like that? I said, well, yeah, I've had IBS for a bit. And we we did a session and he recorded it. And then I took the recording home and sort of for for 10, 20 minutes every morning, I did this um hypnotherapy and I'll explain a bit more about what it is. And within I didn't do anything for about a month, but then after after about six weeks, it started to to get better. And then within two, three months afterwards, it's only come back sort of once or twice when I was very, very stressed. Um so it was I was just absolutely blown away by it. I think a lot of people have kind of uh sort of quite odd, you know, I I I've never been taught about hypnotherapy at med school. Um I was very dismissive of it. I, you know, thought of hypnotherapists as sort of, you know, people on stages getting getting, you know, audience members to come up and sort of cluck like chickens or um or things like that or it seemed quite sinister taking over someone's brain and taking control away from them. Um but it's not like that at all. It's essentially getting you to just completely relax and to direct the focus of your attention in different ways. And then through that, um the suggestions of the the hypnotherapist, the theory is that you're you're more likely to to take on what they're saying on on board. It's it's what I had essentially was quite similar to a sort of a very relaxing type of CBT with visualization. I think I don't want to say that hypnotherapy is a miracle cure for everyone because it's not. And there are lots of different types of sort of talking therapies. Um and um you know, some people are evangelists for for specific ones. But actually, I think there are there are a number that have shown to be beneficial um with people with persistent pain and it might be different for other people, for specific people. But I think they need to have, I think, convey a sense of safety and a sense of hope as well. But the interesting thing about the the the hypnotherapy I had was it um focused a lot on on visualization. And I think visualization is really really um useful because a lot of our most of our brain, well not most of our brain, but a large part of our brain is dedicated to visual processing. Um and my um IBS had become sort of etched on my brain. It had become rewired on my brain. And I thought, well, you know, what's a good way of tackling this is actually through um is through using sort of visual visualization and visual cues to kind of to to sort of steal back my brain. Um and so essentially what what what he got me to do when I was sort of relaxed and focusing on different sort of elements of um the environment around me or my body was to imagine my sort of my sort of intestines as a as a rocky rapids and then to gradually and whenever I have a flare up to imagine them as sort of so I live near a very sort of relaxed bit of the Thames to sort of the languid Thames and sort of punts floating down it and um just a just a that very kind of crude sort of visual change. But doing that sort of religiously for for a while really did work. And there have been a number of cases of so there's a quite quite prominent um pain doctor called uh Michael Moskowitz in in um in in the US who had horrendous pain um and what he did was so horrendous sort of sort of persistent neck pain. And what he essentially did, he he did loads of research and he ended up drawing a picture of his brain and all the areas where sort of the pain areas in the brain, there's not a specific pain area, but areas that are associated with pain and he drew them in sort of red and sort of overgrown and covering most of his brain. And then he had another picture of those areas shrinking. And what he did is he just whenever he had a flare up, he just he imagined those areas shrinking. And it didn't again, it didn't work for months, but after a lot of persistence, it actually did work. And that's a very extreme example and I don't think that should be a first line treatment for persistent pain necessarily because it's using using that kind of using visualization and cognition in that sense can be very hard work and it doesn't work for everyone. Um but maybe things like virtual reality might help with that um and and different types of therapy might be able to sort of harness visualization to to help reduce pain.
Dr Rupy: Yeah, that's huge. I mean, there's so much there that I want to pick out on there. So I mean, if anyone's listening to this, I think you've eloquently described all the different areas that perhaps are overlooked today, but will become hopefully more commonplace. But if anyone knows anyone with pain or suffers with pain themselves, there are a few actionable things that you can do. Like you said, your your book isn't designed to be a a self-help book. I think it really leans into the education aspect of those three things that you said. I completely agree. I think better education about what pain actually is is critical because it helps you with all the other elements, the rewiring, the stories that you tell yourself, the understanding about the emotional connection with the severity of your pain, the other ways in which you can alter it using movement and and uh and breath work, I believe you talked about. And then the visualization element, which is uh quite an investment in time. The knitting element, I found really fascinating actually, the fact that these rhythmic movements can be related to serotonin release and and also that that sense of community, I guess, you know, it can be something that you do with people. And I I wanted to ask actually about the the loneliness aspect and how that can exacerbate pain. Um and also the connection between lack of social cohesion and uh and pain. And I think we don't have as much of a problem in the UK, but certainly in the US, there is a an opioid crisis. It's you know, it's certainly been pegged towards disparities in society as well in marginalized communities. You know, the the age old, I think it was like the just say no campaign. I think we're we're realizing how flawed that messaging was because the root cause when you go upstream is not the availability of drugs and the the opportunity to just say no, it's actually something far, far rooted in in the in the societal aspects of why people choose to use pain relieving drugs.
Dr Monty Lyman: Oh, that's that's that's so true. It's a it's a tragic story and and that's a really good point in that it's the people who are who are in pain and using these drugs are not given any other option. But also there is there are huge societal issues that that are driving this. That's been a terrible situation. And I think so again, understanding things from a survival point of view and that pain is a protector, the pain of rejection is very similar to to pain itself. So there was a a study in done in 2015 at UCLA where they had people playing a apparently a very, very boring online game called Cyberball where essentially you're passing a ball between different people, I guess a bit like football. Uh and then at some point, the the sort of imagine the people you're playing with, you can't see them, but you're imagining that you're playing with them, they start passing to each other and don't pass to you. And they were they were also um doing some brain scans at the same time and they found that when you're you're playing this game with them and when you're isolated and rejected, the same areas in your brain that light up when you're in quote unquote physical pain, light up as well. And if you look at it from a protective point of view, if you are marginalized from a a group, a tribe, um people generally, your brain is going to go into a protective mode. And that just that in and of itself is is is, you know, fuel for for pain's fire. And then again, the social isolation is there are some epidemiological studies that say is as bad for your physical health as smoking 15 cigarettes a day due to various different different things. And that that sense of isolation is just so being on being on your own, not being in a group, not being sort of not being um loved or recognized or I guess I guess sort of being able to have purpose and things like that, um directly worsens pain and can make it much more likely for a short term pain to to become wired on on the brain. And that's often what happens. I mean, that's quite a quite a mild example of what happens in persistent pain, but the brain takes memories, but also the the increase of of of sort of danger signals that come through to the brain after pain during the healing process and beyond the healing process, makes the brain on hyper alert for any other um any other kind of pain. And and trauma in the past can can feed into that. Um and past experience can feed into that and past pain and inflammation can can can feed into that. Essentially what there's a there's a phrase in sort of neuroplasticity that um neurons that um fire together, wire together. So essentially if a particular path is used more often than than other ones, then that will get stronger. And then if it's not used, it sort of you lose it or lose it. Um and in in persistent pain, often even when the injury is completely healed, those paths can have already begun the the the stages of sort of rewiring and can become completely lodged in the brain. It's like I it's like sort of running, I like going for runs through a forest near where I live. And if you if you follow one of the the paths through the vegetation that lots of runners go down, then it gets the path gets more consolidated. But if I start to go down somewhere where there's no path at all, then over and I can do that every day over weeks, months, I sort of the vegetation will be sort of beaten down by feet and a new path will be created. It's a it's a slow, slow and steady process, but um that's how pain can get stuck in the brain, but it's also um by understanding that we can begin to actually actually reduce pain and in some cases completely eliminate it.
Dr Rupy: Yeah, yeah. I think that's a really good analogy and and useful way of describing how neuroplasticity works. I think some of us have heard of that neurons that fire together, wire together, but that that sort of patching down the grass and seeing these like well-trodden paths, I think that's a really nice way of conceptualizing it. I I'd love to
Dr Monty Lyman: I was going to say it's almost like it's not quite like learning, but it's like whenever we, you know, learn a new instrument or a new language, we are consolidating different pathways and in a sense, you can you can learn pain. I don't I don't tend to like using that because it suggests that you're actively trying to make the pain worse, but actually that pain becomes learned on the brain, but actually it can it can become unlearned.
Dr Rupy: Yes, yes. Actually, I was going to talk about this a bit later, but why don't we talk about those practices that you've put uh in the book to unlearn the pain. We we talked about one of them, visualization and and um I think it was Moskowitz, is that his name? The the person who had the the research who had the neck pain and through time and time. I think I think with the one one of the things with a lot of these um practices is that it's a it's a huge time commitment. Um you know, it's it's not something as simple as taking a medication, which is obviously, I mean, we're we're obviously going to default to the path of least resistance. You know, we're we're we're we're creatures of sort of like, you know, ease these days. And I think this is just to frame it for the listener, these are tough practices that that will require a lot of investment. Um but but yeah, perhaps we could talk a little bit again about the visualization element and what modern techniques that you think, you mentioned VR, that we could potentially be using in pain medicine to to help people along the journey.
Dr Monty Lyman: Yeah, that's a that's a really good, I think you make a really good point that actually the visualization element is is a time consuming and it can be a very effective, but it can be a tricky one. And I actually, I think, so I kind of it's, you know, the book itself is not a it's not a self-help book, but in the last chapter, I focus on what I see as sort of evidence-based treatments for um different types of persistent pain and often, obviously everyone's pain is unique. Um so different things can work for different people, but I split it into sort of three three things. It's the first one's alteration, so it's altering the environment of your brain, making your brain feel safe in its body. So that's not that's not visualization necessarily. So that's that's one separate one. And then there's visualization, um and then um then there's education, sort of knowledge is power. And I actually, I think if I can maybe start with the first two before I look at visualization potentially, just because I think um the the visualization ones might be at this point in time probably shouldn't necessarily be the first port of call, or if they are, they can be used alongside um uh the other the other elements. So essentially, um alteration, so making the brain feel safe in its body are doing daily practices, doing doing things throughout the day that um can essentially reduce pain. And as I said, make the brain feel safe in its body. So one of these, for example, is movement. And any sort of any kind of movement. Often when we're in pain, we can understandably not want to not want to move at all. And in the past, sort of bed rest was recommended for lots of musculoskeletal issues. Um and actually that's not for most things, that's not actually very for a short period of time, of course, that's that's important, but actually starting to move really gradually within within your abilities at the time and just to persist with that is is so important because that is uh so exercise generally is reducing inflammation and we can talk a bit more about inflammation maybe uh later on, but it's actually sending signals to your brain that your body is strong, your body is safe. Um and in most cases of persistent pain, the the risk of not moving is much worse than the risk of moving. Um obviously with whatever pain condition you have, you talk to um your doctor or clinician about the the safety of being able to move, but in most cases, um you're safe to move. It doesn't mean you need to go and prepare for a marathon, but it's just it's just getting out and doing all kinds of movement. I I I I spoke to Betsan Corkhill who is um she had done some amazing work and studies into knitting and pain and actually it has found that um knitting essentially is is an amazing way of rewiring the brain because it's it's it's it's a a repetitive movement that uses sort of both sides of the body and and the sort of combined sort of visualization in a sense actually and um but also movement and slowly expanding your your sort of your red zone, your area of of of safety. If that makes sense. So when you're in pain, often you can you can become really withdrawn because your brain's in sort of threat mode. But actually it's it's sort of being able to slowly interact with the outside world. So that's movement. Uh and in a sense, things like breathing exercises can be really, really helpful. I won't go into too much detail, but that but they can be really, really helpful. And anything that's it's easy to say anything, you know, reducing your stress, but with anything that reduces stress, reduces can reduce pain um and can reduce inflammation as well. And often there's a sort of 80 20 rule with that. So it's sort of, you know, 80% of the effect of the stress reduction comes with 20% of the effort focusing on the the key things. Um and then diet is a huge element of that as well. It's like um I don't want to use too many analogies, but if our, you know, our body is a beautiful garden and with our diet, we can sort of create good soil for it. And there are some very, again, we can go into a bit more a bit more detail if if we have time, but um there are there are some very basic things that one can do with their diet to reduce inflammation because there's interesting research that suggests that the bridge between short term pain and long term pain can be accelerated by inflammation in the body and and the brain. And actually inflammation in the brain can can can worsen pain. So those are and and then also with sort of alteration, um various different types of of psychological therapies, but also um there are some there are some sort of newer therapies like pain reprocessing therapies that combine pain education with getting people to understand understand their pain and also start to move and then also elements of sort of cognitive and behavioral therapy with that, which I think is is very promising for the for the future. Um so those those are some elements of altering the brain's sort of making the brain feel safe in its body. But I think the most important thing generally is is pain education, is understanding what pain is and what it isn't. I think it's very hard to rewire a system you don't understand. Uh and I don't think understanding your pain will cure your pain. Um although there's some evidence that that some sort of pain teaching courses and really good ones can actually reduce pain intensity. Um but I think that's the logical starting point. And there are lots of free resources out there like um flipping pain is a really good um relatively new national, essentially it's a it's a sort of pain education group, a charity that that that are involved in sort of educating people and there are some amazing resources that they have online. And then there are there are also some um apps that some people find quite useful. Um so there's one called Curable. It's internal it's internal evidence from the app. So, you know, I don't know how but there's there's a there are lots of people who find it very useful and that kind of uses pain education um and and sort of daily practices to essentially focusing on sort of rewiring your brain. So I think pain education is and I think pain education for clinicians as well in in medical school. I think that's that's so key and I think that's um yeah, that's a really important area that I think just everyone in society needs to needs to needs to understand these things and understanding actually that um um social injustice worsens pain. So um basically anything that increases your sense of threat can worsen pain. And the very things that that torturers do to make pain worse, even without minimal physical injury, things like um isolation, verbal verbal abuse, making humiliation, dejection, is something that is can can worsen pain and is exactly the same thing that happens with um people who are marginalized by society or people who are isolated. There are some interesting studies that um a big one in Sweden in 2020 that showed that uh migrants to to Sweden regardless of race were more likely to have pain conditions, sort of chronic pain conditions. And people of the same race who have moved from say there was one study of um this is a bit of a smaller study but of um Indians who've uh migrated to America were more likely to have chronic pain than um Indians from the same area of India back in India. And it's the element of of of of this this was first generation, but the idea of kind of um injustice, um can have even conscious, very conscious and also very subconscious effects on on worsening pain. People who are isolated are much more likely to have pain. So I think there's a huge need for what we call it social prescribing, but I think every not just clinicians, but everyone's responsibility to support people who are isolated in pain, get them to do things where they are moving, where they're interacting with other people, where they're people where they're laughing, they're singing in choirs and things like that and or getting involved in a in a in clubs and things like that. I think that's it sounds very woolly, but actually it's it's neuroscience.
Dr Rupy: Absolutely.
Dr Monty Lyman: So that's that's so that's that's the kind of the the key things, anything that can make the brain feel safe in its body can reduce pain. Um and then and then you've got visualization, which I think there are um some specific things that it can be really useful for. So for things like phantom limb pain, um and um certain types of pain that are very limited to certain limbs in the body, things like um the the mirror boxes can be amazing. So that's that's also very I won't go into too much detail, but essentially it's if you're if you're missing say you you had a left arm amputated, what you do is you put your right arm into a into a box with a mirror in the middle of it and it looks like you have your left arm in the box. And if you and this is assuming that you have pain associated with your um your sort of your phantom limb pain. So usually the limb is sort of stuck in a position because your brain's rewired. It's quite a complex area, but basically the very the very move seeing the very movements of your your the the sort of phantom hand moving can actually sometimes completely eliminate eliminate the eliminate the pain. And then and then VR can be really helpful, I think. There's some studies that um children who have had so in the post-operative period, so they've had operations, um need far less who who've been given sort of post-op VR um sort of relaxation therapy sessions where they can choose to go to to space or to a beach or I think a jungle is another one or something like that. They can they they need half the amount of opioids and they get out of hospital earlier and they recover better. So I think there is some hope for the visualization element of it, but I think there are some really low hanging fruit that that that we can that we can address just single little changes in in people's lives can make big differences.
Dr Rupy: Yeah, that's huge. I mean, there's so much there that I want to pick out on there. So I mean, if anyone's listening to this, I think you've eloquently described all the different areas that perhaps are overlooked today, but will become hopefully more commonplace. But if anyone knows anyone with pain or suffers with pain themselves, there are a few actionable things that you can do. Like you said, your your book isn't designed to be a a self-help book. I think it really leans into the education aspect of those three things that you said. I completely agree. I think better education about what pain actually is is critical because it helps you with all the other elements, the rewiring, the stories that you tell yourself, the understanding about the emotional connection with the severity of your pain, the other ways in which you can alter it using movement and and uh and breath work, I believe you talked about. And then the visualization element, which is uh quite an investment in time. The knitting element, I found really fascinating actually, the fact that these rhythmic movements can be related to serotonin release and and also that that sense of community, I guess, you know, it can be something that you do with people. And I I wanted to ask actually about the the loneliness aspect and how that can exacerbate pain. Um and also the connection between lack of social cohesion and uh and pain. And I think we don't have as much of a problem in the UK, but certainly in the US, there is a an opioid crisis. It's you know, it's certainly been pegged towards disparities in society as well in marginalized communities. You know, the the age old, I think it was like the just say no campaign. I think we're we're realizing how flawed that messaging was because the root cause when you go upstream is not the availability of drugs and the the opportunity to just say no, it's actually something far, far rooted in in the in the societal aspects of why people choose to use pain relieving drugs.
Dr Monty Lyman: Oh, that's that's that's so true. It's a it's a tragic story and and that's a really good point in that it's the people who are who are in pain and using these drugs are not given any other option. But also there is there are huge societal issues that that are driving this. That's been a terrible situation. And I think so again, understanding things from a survival point of view and that pain is a protector, the pain of rejection is very similar to to pain itself. So there was a a study in done in 2015 at UCLA where they had people playing a apparently a very, very boring online game called Cyberball where essentially you're passing a ball between different people, I guess a bit like football. Uh and then at some point, the the sort of imagine the people you're playing with, you can't see them, but you're imagining that you're playing with them, they start passing to each other and don't pass to you. And they were they were also um doing some brain scans at the same time and they found that when you're you're playing this game with them and when you're isolated and rejected, the same areas in your brain that light up when you're in quote unquote physical pain, light up as well. And if you look at it from a protective point of view, if you are marginalized from a a group, a tribe, um people generally, your brain is going to go into a protective mode. And that just that in and of itself is is is, you know, fuel for for pain's fire. And then again, the social isolation is there are some epidemiological studies that say is as bad for your physical health as smoking 15 cigarettes a day due to various different different things. And that that sense of isolation is just so being on being on your own, not being in a group, not being sort of not being um loved or recognized or I guess I guess sort of being able to have purpose and things like that, um directly worsens pain and can make it much more likely for a short term pain to to become wired on on the brain. And that's the very same methods that sort of um people who inflict torture do to to um to people. I I I interviewed a man, uh an Australian man called Evan who was in the Australian SAS and in 2006, essentially he was in a in a training camp in in Australia and was essentially tortured, he was meant to be going through some kind of um interrogation techniques, but the people who who did it essentially abused and tortured him um for about 96 hours until he passed out. Um and he actually didn't have very much sort of physical injury during that that period, but he ended up having horrendous whole body pain for for about uh for seven years. And the only thing that really stopped um that stopped the pain was when his he he finally won his his court case against the the Australian military. Um and it was just that sort of sense of, it's a slightly different thing because I um than isolation, but it's just a sense of injustice, um being oppressed, caused whole body pain. He couldn't go into he couldn't sort of go into a a pool, swimming pool or a bath that wasn't a certain temperature. He sometimes couldn't put his put his boots on. He was in so much pain. The brain had just gone into into hyper hyper vigilance, hyper protective mode. And there are some interesting studies that show that people who have a strong sense of justice, a strong sense that the that the world is, you know, that there's there's good and bad and and these people and people who are very sort of um uh conscientious actually they tend to have worse chronic pain sadly because because and that when I when I read that study as well, I just thought, you know, that that should be a sort of a clarion call for for for for clinicians, but for people to help people who are in really help people who are in um persistent pain because it's just when you're in that position, um it's not impossible, but it's it's yeah, it's impossible to do it on your own. It's so hard to do it on your own. And that's why I think um there need to be structural, whole societal structural changes, but also um I think starting with education for everyone, I think is key.
Dr Rupy: Yeah, I I um I wrote that down in my mind actually, this this this sentence from your book, perceived injustice is like petrol for pain's fire. Um and uh that really did spoke to me and and something that you mentioned earlier as well from my anecdotal experience working in different areas in London over the last 12 years, I've certainly seen people at the risk of confirmation bias here, but I've certainly seen people from uh different backgrounds, migrants, have more sort of severe experiences with pain. And it's a quite a well-known phenomena in the various A&Es that I've worked uh in in North and and East London as well. Um I I could honestly talk to you for so long. There's so many different elements of your book that have given me a new understanding of pain. Particularly in one of the chapters actually where you talk about religion and um the various interpretations from Buddhism and Christianity and Islam around uh their perception of pain and why we experience pain and how it's sort of uh uh related to to this their their faith. Um but I I I wanted to close actually by asking you a bit more about your writing process because there's there's like a wonderful flow through your your book, you know, it's a it's a a great interplay of stories, being vulnerable and telling your your your personal stories as well as uh a lovely sort of um introduction to all these like rich studies that give us a better perspective on pain, um all wrapped up nicely in in the final chapter. What how how do you write? Like how talk me through that process. And you've got some great interviews as well with some incredible people, you know, people who have genetic uh um uh genetic uh snips that that mean that they don't experience pain, they have various uh issues. So yeah, talk me through that.
Dr Monty Lyman: Uh yeah, that's that's a a really interesting question. I think this was just I think unusually for me as an unusually natural process of writing in a sense that actually when I I had this sort of revelation to my to myself that that actually pain is completely different to what I to what I thought it was. And I wanted basically I wanted to have that as the the core of the the book. So I outlined that at the beginning and then sort of bring it home at the end with evidence-based studies. So to to to to to make it practical at the end. But I think I mean, I think the best way of learning anything, I think is with a story. Um you know, I'm currently revising for some um specialty exams at the moment and so much of the stuff I'm doing is just really boring, but they point stuff and I'm just forgetting it all the time. And actually when I if I'm uh reading about it in a in a book or listening to in a podcast, it's just and and it's sort of told in a story, it's, you know, we we were sort of we're made to sort of tell and listen to stories. So I wanted to kind of bring bring out stories throughout the whole uh the whole book um with the kind of the spine of it being knowing that sort of knowing what pain actually is. It's a it's a protective mechanism, it's not a not a detector of tissue damage. Um and then I wanted that to be through interesting studies. So I did do a big literature review beforehand. Um and then also trying to find sort of interesting experiences with different patients who've had who basically who if there's a point I want to make, a really interesting case study of potentially a very rare patient can be a really interesting way of understanding um biology and psychology. So as you said, yeah, the patient the the very small number of people who don't feel any don't feel any pain at all. The good thing about in terms of the writing process is that I had some pain experiences myself that actually it all just came together uh in that sense. And then the the the general idea I wanted it to be sort of biopsychosocial. So I wanted to to have kind of um I wanted to break down dualism or what you were sort of saying earlier and and have that kind of as a theme throughout the whole book, but also have areas that are that are more sort of quote unquote biological, um more sort of psychological, um and more more social and then looking at things like religion and I think I just I think it's just great to understand the whole body, the whole human, using I love using things that kind of seem a bit I did this with the skin book as well, so that skin was something that seemed quite sort of mundane. Um and pain is something that we don't really want to talk about and I wanted to use these things as prisms through which we can see the kind of the beauty of humanity and and and the body and society, the the positives, the the negatives and I that was kind of the the way I wanted to do it. But I think it definitely this I found it I found this very natural to do because it was there was a it was a genuine revelation uh to me that made me want to write the book whereas with the the book about skin which I I love writing, it was I had to be more sort of rigid and structured if that makes sense.
Dr Rupy: Yeah, that's brilliant. And and and you're you're working on a few other things at the moment. So uh moving towards psychiatry, but you're also an academic clinical fellow and you have an interest in uh the gut brain axis and the microbiota. Tell us a bit more a bit about that.
Dr Monty Lyman: Yeah, so I wasn't at medical school, I wasn't interested in diet at all. I was
Dr Rupy: No, neither was I.
Dr Monty Lyman: It's we're told about it and it's um and I was I was quite sporty at when I was a teenager, did did triathlons and and running and things like that. And I kind of I was always like, oh yeah, I sort of um I eat to live, I don't live to eat. I can eat whatever I want because I'm really fit, which is probably a terrible terrible thing for me at the time. And I didn't really think nutrition played that much of a a role in physical health. But in all the so I'm really interested in the relationship between the body um the body and the brain uh and improving psychiatry through that. Actually looking at the relationship between the gut and the brain and the the effect that the gut has on the brain and vice versa is amazing. And I'm starting to try and get to grips with the gut microbiome. The research that I might be doing is are we trying to adjust the gut microbiome whether it's by um by diet or prebiotics or whether in certain groups it might be assisted with a medication potentially to improve cognition um in in different um conditions, whether it's so the things I'm I'm interested in are are people with psychosis and schizophrenia, a huge part of their life is is ruined by reduction in um cognition and not being able to do tasks or remember things very well. But also people living with long COVID, um or long long COVID, ME, um post-viral syndromes who have terrible sort of cognitive issues that are seem to be largely related to inflammation and you know, if we alter the gut microbiome, then you know, we can make huge huge leaps there. And actually I've started to to change my own diet over the last year kind of because of that and I found that um I've actually noticed a huge changes in my my energy, my alertness, um and my overall mood and well-being through some just some some some some minor changes, which are essentially um eating lots of different types of plants to increase fiber to kind of feed my my my gut microbes and sort of um having more fermented food in my in my diet. And I'm planning to I'll try and see if I can make more changes, but I'm I'm trying to do things things gradually.
Dr Rupy: That's epic.
Dr Monty Lyman: Yeah. So I've been so it's just I think it's I think the the yeah, the gut the gut brain relationship is just so interesting. It's also very very complex, which makes it tricky, but also very very fun and very interesting. You know, the the immune system, the probably the most complex elements of the human body are probably the immune system and the immune system, the the microbiome and neuroscience and they all kind of merge together in terms of um diet, the gut and the brain. And I think there's I think it's going to be a huge change in um the way we treat and prevent diseases through diet is going to be it's going to be huge. And like the work that you do is incredible in that in that sense. So it's yeah. So I think a lot of the research I might be doing will be looking into into the gut microbiome.
Dr Rupy: That would be fantastic. I mean, if you can deal with the complexity of pain and look at the different um triggers and uh the complexity of emotions and all these different things that have an interplay with with how we perceive pain, I'm I'm confident you're going to do a great job with the the gut brain axis and the microbiome microbiota. So please do write a book on that and please do like chronicle everything that you do as you go along because I I would be fascinated to to hear your interpretation of of the field as it is and where you take it going forward as well.
Dr Monty Lyman: I'm planning to, yeah, I'm planning to write um to to to see how this goes. I think it's going to be exciting period.
Dr Rupy: Brilliant. Yeah, yeah. No, I'd love that. And uh and please do come on again whenever you want to talk about that stuff because uh obviously I I love it. So yeah, yeah. And if you need any people that you need to interview, I've got a a number of suggestions. I'm sure you're already aware of uh APC and the night lab and obviously Tim Spector's work and stuff. So yeah, I think those are definitely people that you'd want to feature in the book and uh yeah, no, that that that sounds wonderful. Great. Well, thank you so much, Monty. Honestly, this has been such a great conversation. I love the book. I I really genuinely love it and I can't wait for people to read it. It's it's fab.
Dr Monty Lyman: Thanks so much, Rupy. Absolutely love the chat. Thank you.
Dr Rupy: Thank you so much for listening to this week's podcast episode. Remember, you can get the book, The Painful Truth. The uh link is in the caption on whatever podcast player you're listening to. Connect with Monty at Monty_Lyman on Twitter, on Instagram. The links are all there as well. And don't forget to download the Doctor's Kitchen app and also check out the newsletter at thedoctorskitchen.com. I'm sure you'll find it useful and inspiring every single week and I will see you here next time.
