Do You Have Trouble Sleeping?

Millions of us move through our days without getting enough sleep. We know that sleep deprivation can affect our physical health and our mood. But sleep researcher Chris Barnes says a chronic lack of good sleep can also affect how we make decisions and even what we value. He joins us to explore the forces that keep us from getting the rest we need, and offers practical strategies for getting better sleep. Later, psychologist Rachel Zoffness returns to answer your questions about the experience of pain, in our latest installment of "Your Questions Answered."

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Shankar Vedantam?

  This is Hidden Brain. I'm Shankar Vedantam.

• 0:04Shankar Vedantam?

  Across the world, many countries are experiencing a sleep crisis.

• 0:10Shankar Vedantam?

  In 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.

• 0:23Shankar Vedantam?

  Sleep deprivation can make us groggy and irritable. 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.

• 0:42Shankar Vedantam?

  This 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.

• 1:08Shankar Vedantam?

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• 1:39Shankar Vedantam?

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• 2:23Shankar Vedantam?

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• 2:42Shankar Vedantam?

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• 3:15Shankar Vedantam?

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

• 3:38Speaker 01

  I'm happy to be here, Shankar.

• 3:40Shankar Vedantam?

  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?

• 3:51Speaker 01

  So William Rockefeller was a train engineer in New York. And he had a route that started early in the morning from Poughkeepsie headed to New York City.

• 4:10Shankar Vedantam?

  So 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.

• 4:19Speaker 01

  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, but he did not slow his train down to that speed fast enough to avoid a disaster.

• 4:54Shankar Vedantam?

  I understand that he hit the brake, but just not in time?

• 4:58Speaker 01

  Yes, it was too little, too late, and the train derailed. Four people were killed and 60 were injured.

• 5:08Shankar Vedantam?

  So when investigators looked into the source of the problem, tell me what they found.

• 5:14Speaker 01

  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.

• 5:41Shankar Vedantam?

  So 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?

• 5:50Speaker 01

  Exactly.

• 6:02Shankar Vedantam?

  I understand this train operator also suffered from sleep apnea, Chris?

• 6:07Speaker 01

  Yes, he had a history of sleep apnea, which is a sleep disorder that is very disruptive to people's sleep. Essentially, 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, because they're just too numerous and you're kind of groggy when they happen.

• 7:02Shankar Vedantam?

  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?

• 7:14Speaker 01

  Well, they mentioned several causal factors, one 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.

• 7:47Shankar Vedantam?

  So 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.

• 8:04Speaker 01

  So 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.

• 8:40Shankar Vedantam?

  What happened?

• 8:42Speaker 01

  So a train was already on those same tracks, headed 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.

• 9:14Shankar Vedantam?

  I 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.

• 9:32Speaker 01

  Exactly. Fell asleep at the wheel and woke up as his vehicle was going down that embankment onto the train track. But that was obviously too late to prevent the disaster from occurring.

• 9:45Shankar Vedantam?

  So 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?

• 10:02Speaker 01

  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. Human 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.

• 10:47Speaker 01

  This is always something that occurs in the context of many other factors, often which operate in concert in the same direction, pushing people towards sleep deprivation.

• 10:58Shankar Vedantam?

  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?

• 11:15Speaker 01

  Exactly. On other days of driving, they were perfectly safe. They did not fall asleep at the wheel. And 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.

• 11:28Shankar Vedantam?

  So 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?

• 11:40Speaker 01

  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 are 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.

• 12:08Shankar Vedantam?

  And you also had another little one at home at the time?

• 12:12Speaker 01

  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 and changing diapers and just trying to survive.

• 12:36Shankar Vedantam?

  Yeah. So one night you get an urgent call from your mom. Describe for me what she said and what happened next, Chris?

• 12:44Speaker 01

  So for context, my, 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, that call that perhaps my father was dying. So in this particular occasion, my mother called me at three in the morning. And that timing is already indicative that something is not, 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.

• 13:26Speaker 01

  And so my first thought was, okay, this is the call I've been expecting. I need to go see them right away. Like, this might be my last chance to see my father while he's still alive.

• 13:42Shankar Vedantam?

  So I'm imagining that you probably hopped in the car and raced to the hospital, Chris?

• 13:47Speaker 01

  Exactly. So the, 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.

• 14:06Shankar Vedantam?

  So tell me what happened once you got to the hospital. How was your dad?

• 14:10Speaker 01

  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, 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.

• 14:34Shankar Vedantam?

  So I'm imagining you must have jumped back in the car and now tried to race home?

• 14:39Speaker 01

  Exactly right. So I felt both physically and emotionally exhausted. The, the physical exhaustion was due to an accumulation of sleep deprivation over the preceding weeks and more. And plus the, the awakening and the rapid drive down to the hospital at 3:00 AM, plus the emotional exhaustion of thinking that perhaps this is when my father's about to die. So 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.

• 15:22Speaker 01

  I can only guess, but my, my estimation, it was somewhere around three to five seconds, going straight on I-5 at highway speeds.

• 15:35Shankar Vedantam?

  Now, three to five seconds going at 60, 70 miles an hour, you cover a lot of distance in three to five seconds, Chris?

• 15:43Speaker 01

  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. And 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.

• 16:24Shankar Vedantam?

  So we've been talking about individual stories here. And people can say, well, these are anecdotes, but 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?

• 16:41Speaker 01

  Yes, this is quite an interesting pattern that my co-authors and I found. When my co-author, Sam Yehm, 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 was that there is a spike in car crashes, both in Singapore and Taiwan, following major soccer games that are played in Europe.

• 17:10Shankar Vedantam?

  And presumably that's because the games in Europe are played at a time when it's presumably early, early morning in Asia?

• 17:17Speaker 01

  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 as 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 observed in the data.

• 18:02Shankar Vedantam?

  You studied taxi crashes with a large taxi company in Singapore and, and also another data set which, which tracked really all auto crashes in Taiwan over a period of a few years?

• 18:14Speaker 01

  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.

• 18:29Shankar Vedantam?

  Wow.

• 18:29Speaker 01

  So if those teams are more popular, then we see a larger spike in car crashes the next day in both Singapore and Taiwan.

• 18:46Shankar Vedantam?

  When 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. When 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 Vedantam.

• 19:27Shankar Vedantam?

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• 20:09Shankar Vedantam?

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• 20:48Shankar Vedantam?

  in all states. This is Hidden Brain. I'm Shankar Vedantam. How 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. At 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.

• 21:31Shankar Vedantam?

  Chris, 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 Narbek Ulu. Paint me a picture of what happened that day, Chris.

• 21:52Speaker 01

  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 onto a sidewalk and accelerated, running his car into a crowd of people there. Immediately after plowing into the crowd of people, he exited this vehicle and fled the scene. He ran away.

• 22:14Shankar Vedantam?

  Do we know what happened that day and how the accident came about and why he ran away, Chris?

• 22:20Speaker 01

  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 while 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.

• 23:05Shankar Vedantam?

  So what strikes me about this 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?

• 23:25Speaker 01

  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 across 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. So it's perhaps not surprising

• 24:08Speaker 01

  that people make poor decisions in these contexts.

• 24:21Shankar Vedantam?

  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?

• 24:33Speaker 01

  Yes. 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. Fortunately, 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

• 25:18Speaker 01

  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 behaving more unethically or less unethically on different days, based in part on how much and how well they slept the night before.

• 25:42Shankar Vedantam?

  And when you say sleep deprivation, Chris, are we talking about an hour less of sleep, five hours less of sleep?

• 25:48Speaker 01

  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 body 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 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,

• 26:29Speaker 01

  their moral awareness is lower. So they're less likely to even appreciate that there's a moral aspect to 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.

• 26:55Shankar Vedantam?

  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. Tell me what happened, Chris?

• 27:08Speaker 01

  So she had called into a live ESPN radio show. She's an ESPN sports analyst. And she was covering the NFL Combine in Indianapolis.

• 27:20Speaker 02

  She joins us on the Home of the Bears ESPN 1000 on the hotline.

• 27:24Speaker 01

  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 on her face. And then at some point, she rips out her earbuds and says an expletive live on the air.

• 27:43Speaker 03

  And then everybody else, they kind of unfolded. All right.

• 27:51Shankar Vedantam?

  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?

• 28:03Speaker 01

  Sleep 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 is 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.

• 28:48Speaker 01

  And so we get big emotional reactions when people are sleep deprived.

• 28:55Shankar Vedantam?

  There'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.

• 29:14Speaker 01

  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 raining 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, but also the long commute.

• 29:57Speaker 01

  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.

• 30:07Shankar Vedantam?

  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.

• 30:23Speaker 01

  Yes, so this is why I'm a little skeptical when people say missing 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.

• 30:37Shankar Vedantam?

  There was even a recent report that looked at the relationship between nuclear disaster and sleep deprivation. Tell me what this found.

• 30:45Speaker 01

  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 between 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.

• 31:28Speaker 01

  So 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. That's when we see that it has happened, at least in those particular events.

• 31:49Shankar Vedantam?

  You know, many 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.

• 31:57Speaker 01

  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 and 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.

• 32:35Shankar Vedantam?

  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.

• 32:54Speaker 01

  So 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, turned over sideways. And the pilot was able to escape, but the passengers, they had multiple layers of harnesses, and they were unable to escape. So they all died. They all drowned.

• 33:30Shankar Vedantam?

  When investigators try to find out what caused the crash, Chris, what did they find?

• 33:36Speaker 01

  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. That's what depowered the helicopter, such that it started its rapid descent.

• 34:17Shankar Vedantam?

  So 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 one hour less of sleep. So it says 6:00 AM on your watch, but your body clock feels like it's still 5:00 AM. 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?

• 34:56Speaker 01

  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 following 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.

• 35:40Speaker 01

  So 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 workdays due to the incident.

• 36:14Shankar Vedantam?

  Many of us don't get the recommended amount of sleep every night. We know it can affect our well-being, our memory, our mood.

• 36:22Shankar Vedantam?

  But what's more surprising is that a lack of sleep can cause poor decisions and even unethical behavior.

• 36:29Shankar Vedantam?

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

• 36:39Shankar Vedantam?

  When we come back, getting to the root of our problems with sleep.

• 36:44Shankar Vedantam?

  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.

• 37:00Shankar Vedantam?

  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 in this podcast feed. It's titled "How Sleep Deprivation Affects Leaders." If you're not yet subscribed, please sign up at support.hidenbrain.org. If you're using an Apple device, go to apple.co/hidenbrain. 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.hidenbrain.org or apple.co/hidenbrain. You're listening to Hidden Brain. I'm Shankar Vedantam.

• 37:48Shankar Vedantam?

  Support for Hidden Brain comes from Air France. Air France Business Cabin offers comfort throughout the journey with priority check-in, boarding, and lounge access. Onboard, enjoy menus from renowned French chefs, wines and champagne selected by a sommelier, and free high-speed Wi-Fi. When it's time to rest, settle into a fully adjustable lie-flat bed with added mattress comfort. The art of travel, elevated, because Air France Business Cabin goes further in every detail to make your journey exceptional.

• 38:21Shankar Vedantam?

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• 39:05Shankar Vedantam?

  Now available in Canada and the UK, too. And when Quince asks where you heard about them, let them know it was Hidden Brain.

• 39:16Shankar Vedantam?

  This 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 [email protected]. Use the subject line "Sleep." Again, that email address is [email protected]. We often think of sleep deprivation as a personal problem, something that affects

• 39:56Shankar Vedantam?

  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. At 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?

• 40:32Speaker 01

  So, most of us need between seven and nine hours. Of course, people hear that and they hear, "Oh, okay, seven is fine." So 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-aged children, 10, or maybe even more for the youngest school-aged 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 and that maybe it's fine for everyone else to get eight hours of sleep, but I'll be just totally

• 41:15Speaker 01

  fine if I get four hours of sleep because I am somehow above the need for sleep. It's an unfortunately common belief.

• 41:22Shankar Vedantam?

  Can you talk about the importance of not just enough sleep, but of getting deep sleep?

• 41:29Speaker 01

  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 aspect 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, in three, non-rapid eye movement sleep, there are some very important

• 42:12Speaker 01

  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.

• 42:29Shankar Vedantam?

  Let'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?

• 42:39Speaker 01

  Yes. 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 is sort 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

• 43:24Speaker 01

  of course, all the bad things that happen when you get less sleep.

• 43:27Shankar Vedantam?

  So, 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?

• 43:37Speaker 01

  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 light 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.

• 44:19Speaker 01

  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 dysregulation issues that we tend to face in our modern society.

• 44:34Shankar Vedantam?

  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 is 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?

• 45:10Speaker 01

  Yes. So, there is an idea floating around out there that if I'm really important, then I don't have time to sleep. And then if I am especially capable, that I have less need for sleep.

• 45:24Speaker 04

  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.

• 45:31Speaker 05

  I know there's some out there that say, "Whoa, whoa, whoa, whoa, I need eight." But I say, "Just sleep a little faster."

• 45:38Speaker 06

  The reason I wake up at 4:30 in the morning is because no one else is awake yet. So, that gives me the opportunity to do things that I...

• 45:42Speaker 07

  Rich people don't sleep eight hours a day. That's a third of your life.

• 45:46Speaker 03

  To get through your entire day with little to no sleep.

• 45:50Speaker 01

  So, 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 this, 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.

• 46:32Speaker 01

  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. So, 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 don't... they're not perceived as stronger for bragging about their sleep deprivation.

• 47:16Speaker 01

  So, big picture here, it appears that there's some rationality here where people suspect that there are some social gains that they can 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.

• 47:38Shankar Vedantam?

  A reminder, have you experienced serious adverse consequences of sleep deprivation? If you have a personal story you'd be willing to share with the 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 [email protected]. Use the subject line "Sleep." Again, that email address is [email protected].

• 48:21Shankar Vedantam?

  Chris, 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?

• 48:38Speaker 01

  So 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. And beyond just the transition periods, being in daylight saving time is a prolonged, multi-month exposure 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

• 49:21Speaker 01

  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 in 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's 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

• 50:05Speaker 01

  have better outcomes when we have permanent standard time. If we don'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, what 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. Some people even say, let's make permanent daylight saving time so that I can always have that sunlight in the evening.

• 50:43Shankar Vedantam?

  Are there other policy recommendations that you have, Chris, for improving sleep quality at a societal level, not just at the level of individuals?

• 50:50Speaker 01

  Yes. So 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. So I remember when I was in high school, school started at 7:30, which is an unreasonably early time for a teenager. That's, if you can imagine, for an adult, starting their workday 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

• 51:34Speaker 01

  quite powerful, would be to apply some of the 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. These rules are there because if we don't follow those rules, then really bad things tend to happen, right? People crash their cars, they crash their planes, they make medical errors. We still have a lot to learn, and

• 52:18Speaker 01

  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, it'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.

• 52:57Shankar Vedantam?

  I'm wondering whether you've applied any of these ideas to your own life, Chris? When you have trouble sleeping, what do you do?

• 53:03Speaker 01

  So I will try to do a self-check. How do I feel right now? 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 on 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.

• 53:58Shankar Vedantam?

  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 are 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 after, he suffered from phantom pain in the limb that was no longer attached to his body.

• 54:38Speaker 05

  I would get this unbelievable, sudden, jolting pain that would hit me and just wake me from my sleep. It was really unbelievable.

• 54:49Shankar Vedantam?

  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 reinnervation.

• 55:04Speaker 05

  That's where they go in and they find the nerves that's sending the phantom limb pains to the brain, clips 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."

• 55:27Shankar Vedantam?

  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.

• 55:37Speaker 05

  It's like the pins-and-needles sensation when your arm 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.

• 55:59Shankar Vedantam?

  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 our brains. When we come back, psychologist Rachel Zoffnitz 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.

• 56:45Shankar Vedantam?

  Support for Hidden Brain comes from Instagram. Instagram teen accounts' automatic protections limit who can contact teens, the content they can see, and the time they spend on the app. Teens are automatically placed into teen accounts. Teens under 16 will need a parent's permission to change any of those settings to be less strict. Learn more about teen accounts and Instagram's ongoing work to protect teens online at instagram.com/teenaccounts.

• 57:15Shankar Vedantam?

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• 57:50Shankar Vedantam?

  This is Hidden 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 of the ability to work, the urge to exercise, even the desire to do fun things with friends. We talked recently about chronic pain and how to cope with it with Rachel Zoffness, a

• 58:34Shankar Vedantam?

  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 Zoffness, welcome back to Hidden Brain.

• 58:57Speaker 03

  One of my favorite ever podcasts. I'm so happy to be here.

• 59:01Shankar Vedantam?

  Rachel, we talked in our earlier discussion about how you frame pain as being bio-psychosocial in nature. Explain that term to me.

• 59:10Speaker 03

  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 the 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 bio-psychosocial. So if you imagine a Venn diagram with three overlapping circles,

• 59:53Speaker 03

  these are the factors that contribute to pain. We have the biological factors that contribute to pain in one of the circles, psychological factors 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 important when it comes to pain. But what I want us all to notice is that if

• 1:00:38Speaker 03

  we're only focusing on the bio domain of pain, we are missing 2/3 of the pain problem.

• 1:00:46Shankar Vedantam?

  Hmm. 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.

• 1:00:58Speaker 05

  I had chronic back pain for over 25 years, and my wife had chronic 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, also about a year and a half." And we realized we'd been divorced for two years,

• 1:01:40Speaker 05

  and all of our chronic issues had gone away.

• 1:01:44Shankar Vedantam?

  Does Bruce's story surprise you, Rachel?

• 1:01:47Speaker 03

  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 many 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, you know, 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

• 1:02:29Speaker 03

  domain of pain. So when I was writing Tell Me Where It Hurts, I really went down the rabbit hole to explore the 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 wanted to find those terms a little bit. When I say a healthy relationship, I

• 1:03:07Speaker 03

  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 prosocial relationships. And toxic relationships are relationships that are typically high conflict, high stress. They're characterized by things like gaslighting or estrangement, a lot of conflict. And each has a different neurobiological impact on the human body. Healthy relationships, it turns out, do some of the following things.

• 1:03:49Speaker 03

  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 opioids. 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,

• 1:04:33Speaker 03

  estrangement, conflict, and stress, do the following. They trigger an 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 physical health, always. And of course, that affects our pain. So this story was mind blowing and a little

• 1:05:15Speaker 03

  bit funny. I wonder if listeners are chuckling to themselves. I certainly did. But no, overall, it isn't that surprising.

• 1:05:21Shankar Vedantam?

  Hmm. 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 pain.

• 1:05:39Speaker 03

  I've been struggling for years with interstitial cystitis, which is a 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 of years, I've been really struggling with it in 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 like I didn't want to live if I needed to be just enduring constant pain, living extremely defensively around, like, being afraid to eat anything, being afraid to do anything that could cause me

• 1:06:24Speaker 03

  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, like, basically war against my body. I felt like 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,

• 1:07:06Speaker 03

  I now am living normally again. I have the occasional flare day, but for the most part, I can eat what I want. I can do what I want. And I believe that I am okay.

• 1:07:18Shankar Vedantam?

  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.

• 1:07:27Speaker 03

  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. The 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.

• 1:08:09Speaker 03

  You shouldn't run on that broken ankle. If you do, you will do grievous harm to your body." That 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 catastrophe.

• 1:08:43Speaker 03

  All 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 really 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,

• 1:09:28Speaker 03

  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 the 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.

• 1:10:01Shankar Vedantam?

  When we come back, is there such a thing as fake pain? You're listening to Hidden Brain. I'm Shankar Vedantam.

• 1:10:18Shankar Vedantam?

  Support for Hidden Brain comes from Southern New Hampshire University. Science consistently tells us, learning starts with motivation. That's why SNHU offers over 200 flexible, affordable online programs to help you get where you want to go. Take classes that spark your curiosity, shape your skill set, and prepare you for what's next. A degree can help move you forward, no matter what motivates you. Start yours at SNHU.edu/brain.

• 1:10:50Shankar Vedantam?

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• 1:11:24Shankar Vedantam?

  This is Hidden Brain. I'm Shankar Vedantam. 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 Zoffnis, pain isn't just about biology. It's also rooted in our emotions, in the circumstances of our daily lives, and the societies in which we live.

• 1:11:59Shankar Vedantam?

  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 Fay. Five years ago, I suffered a severe third-degree scald on my right thigh. For a third-degree scald, I should have been given painkillers. When I asked for pain relief, the doctor dismissed me. "You are a woman. You can handle childbirth. And the bone pain is second to the pain of childbirth. So no painkillers for you." It was a mess, and the care was shockingly unprofessional.

• 1:12:38Shankar Vedantam?

  "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 patients. How is this problem being addressed by the medical community?

• 1:13:00Speaker 03

  Oh, God, it's a mess. We continue to see these great discrepancies in medicine, 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 women 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,

• 1:13:44Speaker 03

  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 more 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.

• 1:14:07Shankar Vedantam?

  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.

• 1:14:18Speaker 06

  They inserted a metal rod into my leg, and there are nails at the ankle and at the knee. And 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, and there are people who have had this surgery that go on to run marathons.

• 1:15:03Speaker 06

  There is nothing wrong with you." 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 again, thank you. I really appreciate your program.

• 1:15:31Shankar Vedantam?

  Rachel, talk about the idea of real and fake pain and why this continues to be so persistent in medicine today.

• 1:15:39Speaker 03

  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 Jessie, 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, what I really hear 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 know that doctors aren't getting the pain education they want or deserve,

• 1:16:23Speaker 03

  and so they're burning out. And what you heard from Jessie's story is that she was told that her pain is purely biomedical in nature. Her pain must be just to do with anatomy and physiology, and the doctor didn't see anything wrong on the scan. Therefore, Jessie should have no pain. Pain is a biopsychosocial phenomenon. And the way I like to talk about this in 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 ingredients, like emotions, because our amygdala is always involved in the pain experience.

• 1:17:06Speaker 03

  And so what Jessie 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.

• 1:17:21Shankar Vedantam?

  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 major 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.

• 1:17:45Speaker 06

  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 anymore. 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.

• 1:18:30Shankar Vedantam?

  What do you think, Rachel?

• 1:18:32Speaker 03

  What a beautiful example from Zara.

• 1:18:39Speaker 03

  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 of 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,

• 1:19:22Speaker 03

  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 an 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,

• 1:20:05Speaker 03

  and 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?

• 1:20:25Shankar Vedantam?

  It can't be Usain Bolt, can it?

• 1:20:28Speaker 03

  Oh, my friend, that man is Usain Bolt. He is the fastest man alive. Now, why 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. And as long as you believe that the damage to your body is the sole cause of pain,

• 1:21:11Speaker 03

  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 pain 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.

• 1:21:53Speaker 03

  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. Pain is always bigger and wider and deeper than just that.

• 1:22:15Shankar Vedantam?

  So it strikes me in listening to several of these listeners' 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 are dealing with chronic pain, but also for providers trying to treat it. There are very serious 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?

• 1:22:54Speaker 03

  Oh, you got it. Chronic pain is extremely complex. And this goes back to that thing where healthcare providers want to understand pain, but we aren't getting sufficient or adequate pain education. And what that leads to is this trickle-down effect where people living with pain then don't understand pain because our healthcare providers, you know, 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.

• 1:23:38Speaker 03

  Pain is ubiquitous and it is coming for all of us one day if it hasn't already, whether it's, you know, 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.

• 1:23:55Shankar Vedantam?

  When we come back, more ideas about coping with chronic aches. You're listening to Hidden Brain. I'm Shankar Vedantam.

• 1:24:11Shankar Vedantam?

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• 1:24:56Shankar Vedantam?

  This is Hidden Brain. I'm Shankar Vedantam. Rachel Zoffnis 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 help?

• 1:25:27Speaker 03

  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, 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 what 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.

• 1:26:09Speaker 03

  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 exercise and to play sports and, you know, to roll around with our young kids on the floor or our grandkids and even to have sex with our partners. And, and pacing for 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, you know, tell me an activity that you used to love that pain has taken from you. And some of your listeners in their questions

• 1:26:54Speaker 03

  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, and so we, we pick one 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.

• 1:27:37Speaker 03

  And we slowly, gradually work our way up from our baseline until we achieve our goal, until we're running that marathon. And what pacing does is it helps our brain and body adapt and adjust and get stronger slowly over time until we are re-engaged with the world, both physically and emotionally and socially.

• 1:28:05Shankar Vedantam?

  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 injuries. 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.

• 1:28:50Shankar Vedantam?

  I kept a bit of distance for a while from friends who were discouraging or 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?

• 1:29:18Speaker 03

  Jean's story really strikes me because it seems like mindset shouldn't matter. Like, the 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, and I mean 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 in not just pain intensity, but also frequency and disability. So for, for me, the question was why?

• 1:30:02Speaker 03

  And here's the answer. Thoughts don't just occur in the space between our ears. Every thought we think triggers a neurobiological 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 do 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.

• 1:30:48Speaker 03

  It can also reduce our risk of health conditions like cardiovascular disease. And crazier, it 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 is enraging. Pain stops us in our tracks and prevents us from engaging in beloved hobbies.

• 1:31:31Speaker 03

  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.

• 1:31:57Shankar Vedantam?

  We 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.

• 1:32:06Speaker 07

  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, or 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

• 1:32:48Speaker 07

  market, which I frequent twice weekly. Or more importantly, I'll find someone, maybe a neighbor, maybe someone from church who is in need and help them. And before I know it, my pain is gone.

• 1:33:10Speaker 03

  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 and 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.

• 1:33:51Speaker 03

  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.

• 1:34:00Shankar Vedantam?

  So it strikes me that distraction might be a particularly difficult technique for a clinician to suggest. I mean, 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 they just need to think about something else or keep themselves busy to forget about the pain. I'm wondering how, as a clinician, you might recommend some of these interventions without coming across as callous or uncaring.

• 1:34:29Speaker 03

  One of the most important pieces of information I share with healthcare 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 like 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.

• 1:35:12Speaker 03

  We know that our prefrontal cortex, the frontmost part of our brain, operates much like a magnifier. And when we pay attention to a certain body part, the magnifier zooms 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's magnifier is zooming in. Before, you weren't paying attention to it. Who cares about your left foot? Now that you're thinking about it on purpose and you're attending to it, your brain is zooming in and those sensations are magnified. What's cool about this pain dial is that the opposite is also true.

• 1:35:52Speaker 03

  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 way I recommend strategies 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

• 1:36:35Speaker 03

  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 hope is an important ingredient for healing.

• 1:37:00Shankar Vedantam?

  Rachel Zoffness 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, thank you so much for joining me today to answer listener questions.

• 1:37:15Speaker 03

  Thank you for your great podcast and for disseminating great science.

• 1:37:23Shankar Vedantam?

  We also heard today from University of Washington sleep researcher, Chris Barnes.

• 1:37:29Shankar Vedantam?

  Problems like sleep deprivation and chronic pain can have profound implications for our physical and mental health.

• 1:37:36Shankar Vedantam?

  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.

• 1:37:54Shankar Vedantam?

  Hidden Brain is produced by Hidden Brain Media. Our audio production team includes Annie Murphy-Paul, Kristin Wong, Laura Kwerel, Ryan Katz, Andrew Chadwick, and Nick Woodbury. Tara Boyle is our executive producer. I'm Hidden Brain's executive editor.

• 1:38:12Shankar Vedantam?

  I'm Shankar Vedantam. See you soon.

• 1:38:30Speaker 03

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• 1:39:12Speaker 03

  Welcome to Science of Perception Box. Perception Box. Perception Box. One's own perception of consciousness. The Perception Box. Hi, I'm Elizabeth Koch. What's a Perception Box? You could think of it as a kind of reality filter that's constantly shaping how we see ourselves, other people, and the world around us, yet we often don't even recognize it's there.

• 1:39:32Speaker 06

  Your face is a mask, and you're behind this mask. Science of Perception Box. Listen and subscribe wherever you get your podcasts.