What’s Actually Driving Your Chronic Pain, From A Pain Psychologist

About 16 years ago, an old basketball injury from my days at Columbia flared up. Two extruded discs were pressing on my sciatic nerve, and I could barely walk. Both doctors that looked at my MRI recommended surgery, but I was resistant. Instead, I tried yoga, made changes to my sleep, dialed in on nutrition, and reduced stress. After six months, I was healed completely.

When I told this story to Rachel Zoffness, Ph.D., a pain psychologist and author of the new book Tell Me Where It Hurts, on a recent episode of the mindbodygreen podcast, she wasn't surprised at all. She believes pain is caused by a larger variety of factors than what most doctors look at, and broke down the science behind why I was able to feel better after making lifestyle changes.

Zoffness has spent more than 30 years studying the neuroscience of pain, and her central argument is that what we've been told about pain is radically incomplete.

"The thing that we are told about pain that drives me crazy is that pain is a purely biological, biomedical problem, meaning that it's just to do with anatomy and physiology, and it requires an exclusively or primarily biomedical solution, usually in the form of pills and procedures," she told me.

Legitimate proof that pain can't live in the body alone lies in phantom limb pain. People who lose an arm or a leg often continue to feel terrible pain in the missing limb. If pain could only exist in the body part that hurts, this phenomenon wouldn't exist. This is how scientists know that the brain plays a role in constructing pain.

Zoffness describes pain as biopsychosocial. She suggests imagining pain as a venn diagram with three overlapping circles representing the biological, psychological, and sociological factors that contribute to pain. The biological domain includes genetics, tissue damage, inflammation, anatomy and physiology, as well as lifestyle factors like diet, sleep, and exercise. The psychological domain includes emotions, thoughts, and beliefs. The sociological domain includes socioeconomic status, access to care, social support, and trauma.

One of the most useful frameworks Zoffness introduced me to is what she calls the "pain recipe." Just as there's a recipe for brownies, there's a recipe for every pain experience—a specific combination of ingredients that creates a high-pain day or a low-pain day.

Her own high-pain recipe includes too many hours in front of a screen, skipping movement, poor sleep, a bad diet, and high stress. The low-pain recipe is just the opposite.

This part of the conversation really drew me in, because it honestly explained my own story better than anything else has.

Early in her career, Zoffness tried biofeedback with a physician. He hooked her up to sensors measuring heart rate, skin temperature, and muscle tension, then asked her to think about everything stressful on her to-do list. Her heart rate climbed, her muscle tension spiked, and her hand temperature dropped, just from thinking stressful thoughts. After a short guided relaxation, every number reversed. Within two sessions, she could warm her hands to 90 degrees using her thoughts alone.

From that experience, Zoffness learned the power of your brain over physical sensation."Your thoughts change your body. We all know that. We experience it every day, but no one makes that pathway clear to us," she says.

She also shared a story from her book about a patient who had recently lost her father to pancreatic cancer and was experiencing what she believed was kidney stone pain that she ranked at a six or seven out of 10.

When her husband pointed out the pain had lasted a month, her mind filled with terrifying thoughts of her father's illness. She became convinced she had cancer. Her pain shot to an 11 out of 10. She was screaming. Her husband called 911. When she was examined at the hospital and her scan revealed a kidney stone, her pain immediately dropped to a two out of 10.

Zoffness uses this story to describe how emotion, specifically fear, can alter pain volume. When this patient experienced mental relief, her pain went down too.

If the placebo effect is the brain healing itself through positive expectation, the nocebo effect is its darker twin.

A nocebo occurs when words, context, and negative predictions actually amplify pain volume in the brain. When a doctor says, "There's no treatment for your chronic pain—you're going to have this for the rest of your life," that message doesn't just feel discouraging. It triggers a neurobiological response: endorphin levels drop, muscle tension rises, stress hormones increase, and the pain gets worse.

"Every patient who comes to my office has a nocebo story," Zoffness told me. She says that the words doctors use to describe conditions to their patients are negative messages that actually shape the pain experience.

One of the most interesting things Zoffness brought up to me is how one of the worst punishments we can give a human being is solitary confinement, which should tell us something profound about what we need to survive.

In the presence of other people, our brains produce dopamine, serotonin, oxytocin, and endorphins, which are essentially our body's homemade painkillers. When we're isolated, all of those chemicals crash. And the effects aren't just emotional.

Former U.S. Surgeon General Vivek Murthy compiled years of research showing that loneliness and social isolation are major predictors of chronic pain and disease later in life. Among elderly people who are lonely and isolated, rates of illness and death are significantly higher than among those with strong social support. This is in part because loneliness chronically elevates cortisol, which suppresses the immune system over time.

"Social health is fundamental to our physical health," Zoffness said. "That has been known for a very long time."

Pain is real, it's physical, and it deserves to be taken seriously. But the body-only model leaves out most of the story, and that missing piece is exactly where the opportunity exists for you to take back control over your chronic pain.