Reflections on pain, from the burn unit

Deep frying: even more hazardous to your health than I realized.

Yesterday marked the end of my 18-day stay in New York Presbyterian Hospital’s burn unit, where I landed after accidentally overturning a pot of hot cooking oil onto myself. I ended up with second- and third- degree burns over much of my legs, but after skin graft surgery and some physical therapy, I can walk again, albeit unsteadily, and I have skin on my legs again, albeit ugly skin.

I learned a lot during my hospital stay. Unfortunately, nearly all of that hard-earned knowledge was in very specific topics – the ideal cocktail of pills, the least-uncomfortable position to sleep in, etc. – which will neither be applicable in other contexts nor interesting to other people. But I did leave with one realization about pain, and how we experience it.

I wasn’t in constant pain for the entire 18 days, by any means, but every day featured at least a few painful experiences, from the minor (frequent shots) to the major (scraping the dead skin off the burns). I tried a handful of methods to deal with it. Deep breathing helped a bit, as did pulling my own hair. One friend suggested I try imagining myself existing at a point halfway across the room; that helped a little, but only because our philosophical argument over whether it was even possible to pull off such a mental stunt briefly distracted me from my throbbing legs.

But the one thing that did seem to dramatically affect my pain level was my belief about what was causing the pain. At one point, I was lying on my side and a nurse was pulling a bandage off of one of my burns; I couldn’t see what she was doing, but it felt like the bandage was sticking to the wound, and it was agonizing. But then she said: “Now, keep in mind, I’m just taking off the edges of the bandage here, so this is all normal skin. It just hurts because it’s like pulling tape off your skin.” And once she said that — once I started picturing tape being pulled off of normal, intact skin rather than an open wound — the pain didn’t bother me nearly as much. It really drove home to me how much of my experience of pain is psychological; if I believe the cause of the pain is something frightening or upsetting, then the pain seems much worse.

And in fact, I’d had a similar thought a few months ago, which I’d then forgotten about until the burn experience called it back to mind. I’d been carrying a heavy shopping bag on my shoulder one day, and the weight of the bag’s straps was cutting into the skin on my shoulder. But I barely noticed it. And then it occurred to me that if I had been experiencing that exact same sensation on my shoulder, in the absence of a shopping bag, it would have seemed quite painful. The fact that I knew the sensation was caused by something mundane and harmless reduced the pain so much it didn’t even register in my mind as a negative experience.

Of course, I probably can’t successfully lie to myself about what’s causing me pain, so there’s a limit to how directly useful this observation can be for managing pain in the future. But it was indirectly useful for me, because it proved to me something I’d heard but never quite believed: that the unpleasantness of pain is substantially (entirely?) psychologically constructed. A bit of subsequent reading led me to some fascinating science that underlines that conclusion – for example, the fact that the physical sensation of pain is processed by one region of the brain while the unpleasantness of that sensation is processed by another region. And the existence of a condition called pain asymbolia, in which people with certain kinds of brain damage say they’re able to feel pain but that they don’t find it the slightest bit unpleasant.

The relationship between pain and unpleasantness is a philosophically interesting one, in fact. Unpleasantness is usually considered to be built into the very definition of pain, so it’s quite confusing to talk about experiencing different levels of unpleasantness from the same level of pain. And it’s even more confusing to talk about experiencing no unpleasantness from pain, as people with pain asymbolia do. The idea feels almost as incoherent as that of being happy but not enjoying it, or doubling a number without making it any bigger.

But observing my own experiences of pain a bit more closely has made it a little easier for me to wrap my mind around the idea. I really did feel, when the nurse informed me that she was pulling the bandage off of intact skin rather than burned skin, like the pain was the same but the unpleasantness was lessened. It’s harder to imagine pain with no unpleasantness, but perhaps my shopping bag example sheds a little light: I felt the sensation of something cutting into my shoulder, but it didn’t bother me. So maybe someone with pain asymbolia would experience a cutting sensation as if they’re just carrying a heavy shopping bag, with no “Warning!” and “This is awful!” alarms going off in their mind.

I’ll have to think more about the relationship between pain and the experience of pain, because it’s still confusing to me, but at least I can feel like I got some new philosophical food for thought out of my 18 days at NY Presbyterian. Not to mention the very practical, un-philosophical lesson: don’t leave your giant pots of oil near the edge of the stove.

(ETA: I completely forgot, while writing this, that Jesse had touched on this very subject last month! Wow, Jesse — in retrospect, that’s an eerily prescient post.)

Pain Research: Not Minding That It Hurts

How well can we adapt to pain in the long run? Since pain is such a source of disutility, it’s important for us to learn as much as we can about managing or reducing its impact on our lives. One researcher studying the issue is Dan Ariely, who has a rare perspective after suffering major burns at a young age. He describes some fascinating findings at the beginning of one of his TED Talks (before moving on to his research on cheating), but he devotes a whole chapter to adaptation in his recent book, The Upside of Irrationality.

I haven’t read the book quite yet, but Ariely has posted videos of himself discussing the first few chapters:

Besides being flat-out interesting, pain research could have public policy implications. The current laws tightly regulate the most effective drugs at treating chronic pain, and often discourage doctors (read: scare doctors away) from prescribing them. Earlier this year, Matt Yglesias referenced this kind of research to evaluate some of the costs and benefits of the war on drugs.

This is terrible. One of the most interesting findings from the happiness research literature is that human beings are remarkably good at adapting to all kinds of misfortunes. Chronic pain, however, is an exception. People either get effective treatment for their pain, or else they’re miserable. Adaptation is fairly minimum. The upshot is that from a real human welfare perspective, we ought to put a lot of weight on making sure that people with chronic pain get the best treatment possible. Minimizing addiction is a fine public policy goal, but the priority should be on making sure that people with legitimate needs can get medicine.

Policy decisions require us to weigh the interests of different segments of the population. If we’ve been underestimating the suffering of those in chronic pain, it might be best if we made a shift toward supporting them more and found other ways to offset our worries about addiction.

Another one of Ariely’s suggestions interested me – that events can change the associations we have with pain. I hadn’t given much thought to the dual nature of pain as a physical sensation and an emotional reaction to the sensation. I had always viewed it as a useful but necessarily unpleasant signal that someone is wrong with our bodies. Sure, it’s no fun to experience, but we need to know that we’re putting weight on a fractured bone, right? However, if it’s possible to have that physical alert without the mental anguish, we could get the best (well, the slightly better) of both worlds: notification of problems but not the accompanying distress. As Peter O’Toole said in Lawrence of Arabia: “The trick, William Potter, is not minding that it hurts.

There would be downsides, of course. Pain isn’t just an immediate reaction, it helps shape our future behavior. The emotional component to pain might be important in training ourselves to avoid harmful situations. If we “don’t mind that it hurts” we would probably be more prone to do stupid things.

At the moment, it’s fairly theoretical to me anyway. If we need to go through acute injuries to get to the tolerance Ariely has, count me out – it’s not worth it to me. But we need to understand suffering in order to reduce it, and research like Ariely’s will help.

(Sidenote: I hear Julia will have a chance to meet Dan Ariely at Burning Man this weekend. I couldn’t go because I’ll be on a business trip to Dragon*Con [I know, no sympathy for me] but I hope she has a fantastic time! I’m not envious or bitter at all… )

Why Imagined Indulgence Helps Us Diet

What makes decadent waffles so damn satisfying in the morning? Is it the optimal balance of crispy and soft textures? The fat in the whipped cream? The sugar content? It turns out that there’s a factor beyond the actual food: your frame of mind. A team of researchers at Yale just performed a clever study and found that you feel fuller and more sated if you believe you just ate something indulgent.

As with most psychology experiments, the study involved lying to people. Subjects were given a milkshake on two separate occasions but were told that one contained a whopping 620 calories and the other had a more sensible 140 calories. In reality, both shakes were the same – right in the middle at 380 calories.

Before and after each test, the researchers monitored the subjects’ ghrelin levels as a measure of how satisfied they were. Ghrelin – the hormone which triggers hunger – increases and spikes before meals, then drops off after people eat. If the calorie content were all that mattered, there would be no difference in reactions to the two shakes. But there was:

Results: The mindset of indulgence produced a dramatically steeper decline in ghrelin after consuming the shake, whereas the mindset of sensibility produced a relatively flat ghrelin response. Participants’ satiety was consistent with what they believed they were consuming rather than the actual nutritional value of what they consumed.

What should we make of the finding (besides a continued fascination with the placebo effect)? For one thing, it reinforces the notion that our stomachs are very crude sense organs which aren’t precise or accurate at judging how much food they need.

For anyone trying to achieve (or maintain) a healthy weight, the dynamic makes it tougher to diet. The conscious decision to eat ‘sensible’ food motivates our bodies to demand more calories. What a frustrating situation!

Patrick at Discoblog toys with a creative solution:

It definitely suggests some new approaches to dieting, like berating yourself for eating celery sticks in an effort to make them seem more luxurious and satisfying. But it’s not clear if lying to yourself is as effective as having other people lie to you. And believing that you are constantly eating poorly might have other psychological side effects, one supposes.

I agree, it probably doesn’t work as well to lie to yourself (and nobody will be able to convince me that celery sticks are fatty treats). But we can draw a useful tactic that doesn’t require deception. Instead of applying the study’s findings when we eat light food, keep it in mind when eating dessert. Next time you want a rich slice of cheesecake, look up how many calories it has! According to the study, focusing on the fact that the slice has 50% of your recommended calories will make you feel more satisfied eating less of it.

What I’d like to see is a study that’s honest about the number of calories but emphasizes different ingredients to foster that ‘indulgent’ mindset. Would our bodies react differently to drinking a “300-calorie fruit milkshake” compared to the same one described as a “300-calorie shake with bananas, heavy cream, vanilla extract, and pure cane juice”?

If that works, we can help our friends and families by focusing attention on the fattiest, sweetest, and tastiest part of a dish. Next time Julia is willing to make those delicious-looking blintzes again, sign me up. I can eat one as she tells me about the heavy cream that went into the homemade ricotta.

[UPDATE] I’m looking a little deeper into what exactly was being measured – the abstract and researchers said “Participants’ satiety was consistent with what they believed they were consuming rather than the actual nutritional value of what they consumed.” but news sources report this as well:

The study also didn’t find that the larger drop in ghrelin in those who drank the indulgent shakes was accompanied by a larger drop in hunger levels, a finding that the researchers couldn’t fully explain. “We may not have used a reliable measure of hunger,” says Crum. “My sense is that hunger levels should have changed.”

I had assumed that the participants’ satiety was the same as their remaining hunger – but those two quotes seem at odds at first glance.

The D.I.Y. way of getting a probability estimate from your doctor

One frustrating thing about dealing with doctors is that they tend to be unwilling or unable to talk about probabilities. I run into this problem in particular when they’ve told me there is “a chance” of something, like a chance of a complication of a procedure, or a chance of transmitting an infection, or a chance of an illness lasting past some time threshold, and so on. Whenever I’ve pressed them to try to tell me approximately how much of a chance there is, they’ve told me something to the effect of, “It varies” or “I can’t say.” I sometimes tell them, look, I know you’re not going to have exact numbers for me, but I just want to know if we’re talking more like 50% or, you know, 1%? Still, they balk.

My interpretation is that this happens due to a combination of (1) people not having a good intuitive sense of how to estimate probabilities and (2) doctors not wanting to be held liable for making me a “promise” – perhaps they’re concerned that if they give me a low estimate and it happens anyway, then I’ll get angry or sue them or something.

So I wanted to share a useful tip from my friend, the mathematician who blogs at, who was about to have his wisdom teeth removed and was trying unsuccessfully to get his surgeon to tell him the approximate risks of various possible complications from surgery. He discovered that you can actually get a percentage out of your doctor if you’re willing to just construct it yourself:

Friend: “I’ve heard that it’s possible to end up with permanent numbness in your mouth or lip after this surgery… what’s the chance of that happening?”

Surgeon: “It’s pretty low.”

Friend: “About how low? Are we talking, like five percent? Or only a fraction of one percent?”

Surgeon: “I really can’t say.”

Friend: “Okay, well… how many of these surgeries have you done?”

Surgeon: “About four thousand.”

Friend: “How many of your patients have had permanent numbness?”

Surgeon: “Two.”

Friend: “Ah, okay. So, about one twentieth of one percent.”

Surgeon: “I really can’t give you a percentage.”

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