If you have ADHD or autism, research shows you’re at a much higher risk for developing chronic pain — a connection many doctors and patients still don’t know about. In this episode of Hyperfocus, we talk with a doctor who’s trying to change that. Dr. Michael Lenz, a Wisconsin-based pain specialist, explains what the medical community is discovering about the connection between ADHD, autism, and chronic pain, including conditions like fibromyalgia and migraines. He also shares stories from his practice, including times when treating a patient’s ADHD unexpectedly improved their chronic pain symptoms.
If you have ADHD or autism, research shows you’re at a much higher risk for developing chronic pain — a connection many doctors and patients still don’t know about. In this episode of Hyperfocus, we talk with a doctor who’s trying to change that.
Dr. Michael Lenz, a Wisconsin-based pain specialist, explains what the medical community is discovering about the connection between ADHD, autism, and chronic pain, including conditions like fibromyalgia and migraines. He also shares stories from his practice, including times when treating a patient’s ADHD unexpectedly improved their chronic pain symptoms.
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For a transcript and more resources, visit Hyperfocus on Understood.org. You can also email us at hyperfocus@understood.org.
Rae Jacobson: We've known for a long time that conditions like ADHD and autism often don't ride alone. And some of the comorbidities like depression or anxiety are pretty well known. But it seems like scientists and researchers are always learning new ways that ADHD interacts with our physical health, too.
Chronic pain is technically defined as a pain that lasts longer than three months. But it can also be used as an umbrella term for a bunch of different conditions including, but very much not limited to, nerve disorders, arthritis, chronic migraines, painful periods, and more. It's something I was aware of, but didn't know that much about until our team ran across research that shows that people with conditions like ADHD or autism are a lot more likely to experience chronic pain.
I was shocked, and I wasn't alone. This isn't really that well known by doctors or patients. But on this episode of "Hyperfocus," we talk with a doctor who's trying to change that.
So my guest today is Dr. Michael Lenz. He's a primary care provider in Wisconsin, and what caught my eye is that he's also an expert on the intersection of chronic pain and ADHD and autism.
Dr. Michael Lenz: I'm by nature very curious.
Rae: One of the areas that Dr. Lenz was curious about while in medical school was mental health.
Dr. Lenz: Everybody kind of knows, yes, depression can have impact on your health and we know how that is common. So mental health was always interesting to me, but I didn't want to just be a psychiatrist. I liked all of the organ systems. And I didn't want to be a surgeon.
Rae: So he split the difference and did a program that let him study both internal medicine and pediatrics. And during his training, Dr. Lenz started learning about a set of patients who were coming into the doctor with a different set of symptoms.
Dr. Lenz: There was this pain physician in town with a pain psychologist, and they would have these days where they discussed complicated patients. And he said, "Hey, Mike, do you want to come?" And I'm like, "Sure, I'll learn because I'm just starting." And then I'm like, "Ooh, these are complicated patients."
Rae: I'm Rae Jacobson, and this week on "Hyperfocus," Dr. Michael Lenz and how he came to care for these complicated patients.
These complicated patients Dr. Lenz was talking about were people with chronic pain. People who were in serious distress, but whose conditions — things like fibromyalgia, injuries that hadn't healed, chronic migraines, and more — are notoriously hard to treat. On top of that, by this time, the opioid epidemic was ramping up, with drugs like Oxycontin being pushed by drug companies as a treatment for chronic pain. And physicians like Dr. Lenz were beginning to see patients who were suffering from addiction and becoming wary of prescribing painkillers. But without them, treatment options for chronic pain became even less clear, and many doctors felt that chronic pain cases were just too complicated to take on.
But it was also around this time that Dr. Lenz, with his early training in treating ADHD, began to notice something interesting.
(03:09) The connection between neurodivergence and chronic pain
Dr. Lenz: Along the way, there was a convergence like, hey, there's some overlapping things. Some people get migraines, they have some ADHD. I'm treating that. Their ADHD seems to get better. And it's just kind of anecdotal, but then you're seeing more and more of it. And then you start looking into the literature probably in the maybe around 2018 as you're diving like, hey, I'm seeing two separate things. They seem to help. And then you hear about these studies reporting comorbid ADHD with fibromyalgia. A study came out in 2018 that corroborated my clinical experience. 45% of people in a study out of South Africa were found to have coexisting ADHD, and that was just using a screener questionnaire.
And then looking at more and more research, like, oh, there's other research supporting. I have a couple medical students that were trying to put together studies on my patients looking at what the prevalence of these chronic pain syndromes and comorbid ADHD. And then the autism part, that has always been fascinating and especially in probably the last three years, because as a pediatrician, that was always this mystery group. Like we think of it as the academically challenged child who's nonverbal, who has stereotypical features, who likes to play with trains and line them up.
But it was like, but we were supposed to like, if you suspect it, refer to a specialist. And it's like 1 in 2,500 people, like or so in the 1990s. Well, that was, but that, so it was kind of there, and you'd read a little bit about it. Along the way, I'm interested in mental health as part of this and all the general primary care stuff. And then starting to connect, oh, we have a more modern understanding of updated autism, autistic style brains, and how often there's masking. It turns out these co-occur with ADHD very commonly. It turns out many of them have co-occurring chronic pain syndromes, which to me is really exciting. Actually, when I wrote my book five years ago, I never mentioned the word autism, but I talked about it indirectly because describing patients, now it's just putting a name to these co-occurring patients.
Rae: One of the things that I wonder about with the chronic pain and ADHD overlap — and I was thinking about this earlier is this is in no way relatable, but when I was pregnant, I was so almost unbearably aware of my body because I have ADHD. I'm easily distracted. I'm very like sensory stuff is very tough for me, and I know for people especially who have AuDHD or who are autistic or anywhere really on the ADHD spectrum, sensitivity is big for us.
And it was so hard to concentrate, so much harder than it had been in any other time of my life. And of course there's other reasons for that. But when we started talking about talking to you and I was thinking, God, if you had chronic pain, your ability to focus would be so impacted for so many reasons, but not least of all because people with ADHD have a higher sensory awareness. You know, if I have a tag in my clothes, it makes me insane. I can't imagine if I was in physical discomfort or active pain at all times. So is that something that you see that makes it tougher for people with ADHD in this overlapping world or tougher for people with autism?
(06:22) The double-edged sword of sensory sensitivity
Dr. Lenz: Well, that's often what I call a double-edged sword. So, having a little sense of humor and fun and pragmatics about things is, if I had somebody like you and we were Navy SEALs out patrolling behind the scenes, and you're like, "I heard something. I heard a crack of a twig." And I'm like, "Hey, trust Rae. If she heard something, she hears, she's hypersensitive. She will protect us."
Rae: I really appreciate that you think I would be a good Navy SEAL.
Dr. Lenz: But you might be a good guard dog for the Navy SEALs. You might not be able to shoot a gun or run very fast, but we put her in the unit because she works, she's like the best sensor when our tech goes down. She can hear anything. She can hear anything. She notices something. She smells something.
Rae: Michael, you're giving me a sense of purpose.
Dr. Lenz: Well, the double-edged side is in one setting it could be, but when you're not out in combat, Yeah. and you're in everyday life and you're like, "This isn't really helpful that I notice tags right now. This isn't really helpful that I notice people watching TV for really loud and screaming at the Thanksgiving holiday football game."
Rae: Yeah, I'd rather learn this math than feel the tag on the back of my shirt.
Dr. Lenz: Yes, it's like, okay. But in certain situations, it could be. And then the modern world, where you live in New York City where it's like you can't just go out and have peace outside, walk out your door and be like, "Oh, I got to get outside and get some fresh air." And it's like, actually, I don't know, maybe I should better go inside because it's so loud and noise and you don't know. But back in the day, in one sense, when it was not so much in the modern world of things where quietness was easier and there wasn't so much loudness and all of that stuff.
So getting back to the question, the sensory sensitivity and all of this, that is so integral to chronic pain is that hyperawareness. I had a recent patient of mine who is AuDHD, who has chronic pain, who for the first time just got a follow-up visit for her ADHD as well on Adderall adjusting. And she said, "Dr. Lenz, it's like I got blinders on, you know, those horse blinders? Like I don't notice all these other sensory things. I can lock in."
And so to notice everything is maybe in some situations okay, but it's also like sensory overload. Yeah. And things again that aren't harmful — the tag isn't there, it shouldn't be harming you, but your body thinks of it as kind of a threat. And in one sense, we look at the brain, you have the brain on one side, you have a dog that's a puppy and you're petting it and it's really nice and it's a happy like golden retriever. Yeah. And then the other side is like this wolf tearing off this deer flesh and that is the highly protective part of the brain. And it's kind of like the dog who barks at everybody and they're not going to eat you, but they're really loud and annoying. And then there's dogs that have, they're quiet. They could have a criminal break into your house in the middle of the night, and you pet their tummy and they don't react. So that's a difference in how that nervous system is. And that overresponsive, hypervigilant, hyperprotective nervous system can make your body perceive things. And where is pain? By the way, where is all pain? In your brain and how you process it, that threat detection system.
(09:41) The science behind the overlap
Rae: Research — what little there is on chronic pain and ADHD — bears this out. The heightened sensory awareness and hypervigilance that sometimes comes with ADHD or autism can make chronic pain more intense and more overwhelming. We're less able to turn off or tune out bodily sensations than neurotypical people. And when those sensations are painful and constant, things can become unmanageable very quickly.
There's also new research that suggests conditions like hypermobile tissue — read, joints that bend too much or too far — is associated with ADHD. And more established research that shows a strong association between low muscle tone and autism spectrum disorders. And both hypermobility and low muscle tone are known to be conditions that can cause chronic pain. This research is all pretty new. There's just not that much yet. We're just starting to learn about how all of these complicated conditions interact. And for Dr. Lenz, that learning started in the exam room.
So to all of your learning, you've been doing this for a long time. You're trying, from everything you've said, in your lifelong learning process, you're seeing patients who have chronic pain, you're seeing patients who have ADHD. How did you start to realize that there was an overlap? What like, you know, personally and also like just in the scientific literature, like how do we currently understand the comorbidity of ADHD, autism, and chronic pain?
(11:05) A holistic and narrative-based approach to treatment
Dr. Lenz: So, one is just observation. There are higher rates of these chronic pain syndromes in those who are autistic. There's higher rates of chronic pain syndromes with those who have ADHD. And then pragmatically, I don't treat fibromyalgia directly by using a stimulant medication, but if they have co-occurring ADHD, I'm treating their ADHD, and then, oh, by the way, their brain fog improves, their fatigue improves, and their pain is less.
And I just got a message through my chart from a patient of mine who's in her 50s who just messaged me for the first time in her life, getting treated. And I always say, "Message me in a week, let me know," because we do dose titration with medication, like start on a low dose of Concerta. And she said, "I've been on it for a week, Dr. Lenz, and I notice I'm not as fatigued." Huh. "And I don't notice my pain. It's like it's muted. And, well, it's not gone away, but I can tell after 10 hours it's worn off and it's almost like my pain has come back and seems worse." That is her just as a typical experience, like it's just muted.
And so like one way to think of these chronic pain syndromes is a guitar hooked up to an amplifier. And we can strum the guitar, and if it's not an amplifier, it'll be heard, but not outside this room. But you can crank that up and it's heard even more. And so it turns out when you look at studies and the connections with this, when they do look at those who have the most severe fibromyalgia symptoms, and you can measure that on these questionnaires like the Fibromyalgia Impact Questionnaire Revised and the Widespread Pain Index and Symptom Severity Score, which we use to diagnose. Those who have ADHD have more severe symptoms of fibro. They have a higher impairment, their functional score is worse. And then when you look at studies when they have treated their ADHD, either fatigue levels improve, their pain levels improve as part of that.
Rae: So is that in part because you're treating that hypervigilance, that wolf that's waiting?
Dr. Lenz: Yeah, you're, you're able to like, not the sensory, that's like turned down. And it's, and then also there's this fatigue.
Rae: You mentioned at the beginning that these are complicated patients, that they're, I, you know, I feel like a lot of stigma goes with chronic pain. And the people I know who live with chronic pain often go to great lengths to hide it. And it's in no small part because you mentioned earlier on that people might think they were hysterical or overreacting or being difficult. And I also hear that from people in the ADHD and autism community. You don't want people to know that you're different in a way you can't control. It doesn't feel good. And you expend so much energy trying to conceal who you are and what you're going through from other people all the time. How do you as a doctor help people undo that, that shame, that stigma? Because it's not just the physical experience. It's not just the symptoms, right? There's all this other stuff that comes with it.
(13:55) Combating stigma through validation and education
Dr. Lenz: Yeah. So I'm smiling here because sometimes I will say, "You know, you're not that special."
Rae: It's funny because I know that there's people who hear that and they're like, "Oh, that sounds so negative." But I'm like, "No, that's great. That feels so good."
Dr. Lenz: You know, I take care of a lot of people like you. And when you, and I see a lot of patients with the electronic medical record who I can look through and often they have seen many doctors, maybe referred eventually to me or find me. So I get a chance to see all of the doctor visits. And it's not just years, it could be decades of being misunderstood, not diagnosed or they said, "Well, once I was told I have fibro, but then they didn't really do much for it," or I have chronic pain and I'm left in there.
So a big part of it is just asking probing questions in a neutral way. So what were you, and this is often for people who, most of whom have never been diagnosed as being neurodivergent. They're coming in and they don't know that they're neurodivergent. And then I ask probing questions like, "Well, tell me about starting with maybe childhood, elementary school. What were your things that you were really good at?" And then, "What were some more struggles?" And, and then strength-based, what were maybe struggles. And then you're like, "Well, I, I really talked a lot when I was in school, Dr. Lenz. And well, I didn't really like homework." And, and then you like, "Were there any challenges you went through?" And then you start to hear some of these stories. And then you get to ask questions.
And as you start to get a feel for some of these things and if somebody maybe autistic, "So like what do you think about eye contact with people you don't know real well?" "Well, I don't know. It feels kind of weird, Dr. Lenz." I'm like, "So what have you been looking at right now?" "My chin, your nose, my eyes." I'm like, "Oh, okay. Yeah." And then you start asking some more sensory things like touch and, "What do you think about tags and all of this?" And just to have a doctor ask a question that you may internalize that, "Oh, so you know about us that we might not like tags and,"
Rae: Yeah.
Dr. Lenz: "I notice you got sweatpants on. What do you think about those scratchy jeans?" "Oh, I hate scratchy jeans, Dr. Lenz."
Rae: I mean, 100% agree.
Dr. Lenz: And, and so just validating that a doctor would ask a question.
Rae: I wonder how validating it must feel for your patients to have someone not just take them seriously about their chronic pain, but also really ask questions because I feel like to your earlier point again, this is such a frequently misunderstood group of people. And when you add in neurodiversity, when you add in more complex conditions, I bet a lot of people have spent a lot of time either trying to say like, "No, no, it's probably just me, I'm probably just overreacting," or being dismissed by doctors when they do bring it in. Do you find that people who you work with feel really validated when you do that kind of detective work?
Dr. Lenz: So to add that experience, I think that a lot of patients stop getting back to, they say, "I have a low pain tolerance." And I'm like, "No, you have a low complaint tolerance. You're really struggling." And a lot of people learn to become the good patient. You know what the good patient is? You go to all the specialists. They run the tests. They're all normal. You go to another doctor and they run it and they're normal and you get tests and MRIs and maybe you tried some treatments for spinal injections for pain and all of these things. And maybe you went to a functional medicine doctor and you tried all these supplements and medicine that's alternative that not well supported, and you're still struggling. And so they tell you you're fine. So a good patient stops complaining.
Rae: Yeah. And then you don't get the help you need.
Dr. Lenz: And then you're like, and then you don't get help and you go through this.
Rae: So to that thing, I guess what does help? Like how do you treat people who have ADHD, who have chronic pain? Like what does that treatment look like, especially for people listening who might have had the experience you just talked about?
(17:48) A comprehensive treatment plan for neurodivergent pain
Dr. Lenz: So, one, I like to just start with if I'm seeing somebody, I get their story. And often actually, if anybody's in the area that would ever come to see me, is I like people to write down their story in kind of five-year increments or 10 years if you're in your 70s. What were your strengths? What were your struggles? What kind of diagnoses or symptoms have you had? Because it might have been, "Well, I had stomach pain. I always had constipation as a kid. I got painful periods, had migraines, had some neck pain, this and that. Then there was this life event and then I had..." And going along the way, maybe there was an endometriosis and writing down the stories.
So narratives, giving your narrative and story is so helpful because, oh, when I was in college running and working out every day, I actually did great. But when I got out of college and I got the desk job and then, and then I kind of worked out, but then I had kids and I couldn't work out. And then something happened and then... And so you're like, "Oh, so there is some agency, the sense you have some control over it." So starting with a narrative, okay.
One of the things also is recognizing co-occurring medical things that are low-hanging fruit. Many neurodivergent people, for example, have restless legs syndrome. They're like, they're uncomfortable feeling in their legs, trying to fall asleep at night with the urge to move, and they keep moving during the night and they can't get into deep sleep. If they have sleep apnea, if they have bad sleep hygiene, sleep's super important. If they do have co-occurring ADHD, treat the ADHD. Get that diagnosed.
I assess where somebody's at. There are some medications, SNRIs, which are serotonin reuptake inhibitors that work like duloxetine, milnacipran. There are medications that can be helpful. But the thing about this is most of the medications give a partial relief, especially in the world of like Cymbalta. Like, "Oh, I tried it, didn't help." Like most people think, "Oh, it's going to cure my," like it is like getting your appendix removed for appendicitis. And then lifestyle is so important. That includes diet. Studies have shown a more plant-predominant diet and healthy vegan diet has been shown to reduce inflammation in our body, reduce overall pain.
Good sleep hygiene. Psychoeducation or neuroscience education, like we're talking about this now, is like, "Oh, so my brain works different. A lot of people have this. What can I do to help support my nervous system and brain?" And then actually learning about ADHD and learning about autism and how to support that style of brain can be like, it's okay if you just spend an hour or two at the Thanksgiving with the loud room and just say, "Hey, I'm going for a walk outside because I need fresh air. I'm going to play with the dogs," and maybe do pottery or play fun things outside or — and like, "Oh, that's really helpful." I was talking to somebody here who found — we were talking about this earlier this morning — that, "Oh, I do pottery and ceramics and that actually calms me down."
Oh, what are things that you like? Painting, photography. I've talked on my episode, using music as medicine, photography, playing music, singing music, listening to music you like. Oh, yeah. So there are things that are useful as part of this. And now we're getting more information now about the role of hormones for women who are going through perimenopause. Actually hormones may be helpful. Postmenopause, 20% of women, their fibro starts with menopause or when they're diagnosed as. Oh, so the study's showing that there was a 35% reduction on average in fibromyalgia symptoms in those who are on hormone replacement therapy. So it's multiple things that help.
(21:27) The future of integrated care for neurodivergent patients
Rae: This holistic treatment approach, an approach that takes the whole person into account, seeing and treating them in a multifaceted way is what Dr. Lenz hopes to see become the norm. But he acknowledges that may be an uphill battle. Many doctors don't really understand chronic pain or neurodiversity, not because they don't want to or because they don't care, but because the system isn't really set up to support what Dr. Lenz calls lifelong learning. And when doctors don't have the training or knowledge to help patients, especially complicated patients, people get shut out. But if you've listened this far, you know Dr. Lenz is an optimist, and he's got a vision of what a better future could look like.
Dr. Lenz: The challenging part in medicine is we look at people now in silos. Yeah. And when it comes to the world of ADHD, many primary care doctors who take care of adults have never — their mentor didn't teach them. So when I look back and go, "I was fortunate enough that on my afternoons, I had doctors who were there who felt comfortable back in the '90s when it was just normal." It was like, "Oh, we treat asthma, we treat ADHD, go through these Conner's scales, this is how we do it, adjust it." And now you look back going, "Oh, some regions, if your clinic that you went to with your mentor that didn't do it, and they didn't keep up to date, and they didn't think it was that important, they didn't learn, so then they're not teaching the next generation of things."
So that's a challenge. But it's like, oh, we need more doctors to be aware of this. The positive part is, I gave a talk to a lifestyle medicine group. There's a group that's a new course, an elective course for first-year medical students. They put on eight one-hour lectures on the benefits of lifestyle medicine, healthy diet, exercise, all of that, and how to incorporate that as an optional thing. And I talked at the last day about what I did at the end as people were some people in the community were sharing their stories. And a few of the med students contacted me like, "Can I just shadow you in clinic? That seems really cool what you're doing. I really just want to see that."
And so that's really neat to hear that hopefully that next generation of doctors. And as they say, those who are listening who are medical doctors, be humble enough to re-evaluate these attitudes you may have had to these patients because these are the most stigmatized group of patients. And actually, again, validating to say, you know, "You're not that special." But I also — and they hopefully laugh, most of them like laugh like, "Why would he say that?" Yeah. But also to say, "You're my favorite group of patients." And I said, "You know why you're my favorite? When you can have somebody who's not just had for years, often decades, their whole life, to actually connect the dots and make sense out of this and change the trajectory of their life from hopelessness to actually real hope and benefit and getting improvement, that is so exciting to help people with that, you know?"
Rae: Yeah. That's like working a miracle. I mean, that's the kind of change, I can't imagine providing that for people. That's so amazing.
Dr. Lenz: Yeah.
Rae: Dr. Lenz says that when people hear him talking about chronic pain and neurodivergence, they often reach out. But since he is only one very hardworking guy, we are going to direct you to his podcast, "Conquering Your Fibromyalgia," and the book of the same name. We'll put a link to that and some of the research we talked about today in the show notes.
One other note this week: friend of the show Craig Thomas, who you know and love for being an excellent "Hyperfocus" guest, or, I guess fine for being the co-creator of "How I Met Your Mother," has a new novel out. It's called "That's Not How It Happened." And it's a beautiful, funny, genuinely lovely story about disability and family and how we care for each other. We'll have a link in the show notes so you can check it out.
"Hyperfocus" is made by me, Rae Jacobson, and Cody Nelson.
Our music comes from Blue Dot Sessions. Our research correspondent is Dr. KJ Wynne. Video is produced by Calvin Knie and edited by Alyssa Shea.
Briana Berry is our production director. Neil Drumming is our editorial director. Production support provided by Andrew Rector.
If you have any questions for us or ideas for future episodes, write me an email or send a voice memo to hyperfocus@understood.org.
This show is brought to you by Understood.org. Our executive directors are Laura Key, Scott Cocchiere, and Jordan Davidson.
Understood is a nonprofit organization dedicated to empowering people with learning and thinking differences, like ADHD and dyslexia. If you want to help us continue this work, donate at understood.org/give.