What do you call a shower of yummy tingles over your head, neck, shoulders, and upper back, triggered by gentle, quiet, rhythmic stimuli? What if it came with a pulse of euphoria? Until relatively recently in history, you just called it a weird feeling. Nice! But weird.
And then it got a fancy name: autonomous sensory meridian response (ASMR). It’s a strangely hot topic now. I think I have some unusually good reasons to write about it: it might be relevant to the treatment of pain.
I get these odd “brain gasms” from learning cool things in conversation. More when I was younger — yet another thing age has been stealing from me!
What is ASMR?
What sorcery is this? ASMR isn’t clearly defined in terms of neurology and biology, although some unusual brain activity has been identified.1 Mostly it’s just a distinctive sensory experience. It probably evolved to encourage grooming — one of its most reliable triggers, in much the same sense that biology incentivizes reproduction with orgasms.
More technically now: ASMR is a brief episode of mild euphoria with paresthesia (altered sensation) of the head and neck. It has a bunch of oddly specific triggers, like whispering, loud eating noises, and the sound of someone blowing into a microphone. More generically, it’s most effectively triggered by grooming, complex low-pitched sounds, and slow detail-focused video.2 Weird, right?
A 2019 study showed that the pupils dilate with ASMR tingles — a slight but objective sign.3
ASMR is very similar to a frisson, a pleasant shiver. It also overlaps with sexual arousal, synesthesia (blended sensation, like “seeing sounds”), misophonia (irritation with specific sounds), and flow state (being “in the zone”). Scholars are hard at work trying to precisely define the differences between these phenomena. We wish them luck and many fine thesis papers.
ASMR triggers in healthcare
ASMR has many triggers, and one of the most classic is receiving attention, mostly in a safe and/or caretaking context. So how much does ASMR account for the value of going to see a healthcare professional? What does it contribute to the surprisingly potent placebo/expectation effects that come from working with an attentive healthcare practitioner? Quite a bit, I suspect.
I have had ASMR in doctors’ offices and other kinds of healthcare appointments many times. Massage therapy is chock-a-block with ASMR triggers:
- quiet, repetitive actions
- soft voices and whispers
- interesting and gentle tactile stimulation (especially around the head)
Do we love massage partly because of ASMR? Probably. But the same things are going on to a lesser degree in many other kinds of healthcare. I get it at the barbershop too — from literal grooming!
ASMR as a potent non-specific effect of healthcare
Every time we have any kind of interaction with a healthcare professional, there are countless subtle impacts on our nervous systems. These are the non-specific effects of being cared for and attended to, collectively notorious for being more potent than treatment itself.4 What happens in the “therapeutic interaction”?
Expectations are raised or managed. Hopes are dashed or reinforced. Fears are inflamed or eased. We may feel defensive or collaborative, supported or undermined, amused or disgusted.
It’s mostly psychological, but not entirely. If we are touched — even clinically, even just with cold steel or plastic — we may feel comforted or threatened, warmed or chilled, repelled or aroused. Contact might cause pain or ease it. More rarely, it is pleasurable or luxurious — which is the entire point of some styles of massage.
And we might “tingle” with some ASMR. Because therapeutic interactions are similar to grooming, and therefore full of ASMR triggers.
The peculiar neurology of ASMR exists at the intersection of sensation and psychology. It may be an ideal example of the power of the therapeutic interaction to affect us in complex ways, a blend of psychological, social, and physical.
Other than taking people’s word for it, how do we know ASMR is “real”? When the tingles hit, the pupils widen a little.
Could ASMR treat pain directly, or contribute to therapy for pain?
The short, obvious answer: yes, of course, just like any other pleasant or reassuring experience, but perhaps even more so. ASMR is probably not just a weird, nice sensation — it has predictable effects on mood and physiology, and “may have therapeutic benefits for mental and physical health.”5 This is obviously hypothetical, but also obviously possible.
To the extent that ASMR is a potent non-specific effect of therapeutic interactions, it is at least somewhat therapeutic by definition. Anything that makes that interaction more reassuring can probably boost its power to relieve pain. And ASMR is semi-literally an “orgasmic” positive reinforcement.
Wise therapists already optimize for positive therapeutic interactions, also known as “good bedside manner.” They might go further and make a point of optimizing for ASMR specifically, as the apotheosis of good bedside manner. You know you’re really doing it right when you are triggering ASMR! “Healthcare professionals should be aware of this emerging topic, and the potential for therapeutic applications should be investigated.”6
And a wise patient might seek out ASMR. People already seek out ASMR triggers as a kind of self-directed therapy: YouTube is full of ASMR videos.
Non-specific effects are already well-known for “treating” pain — for actually being the better explanation for why people feel better after receiving therapies that have been proven not to have clinically meaningful specific effects on pain.7 And ASMR might be one of the most potent of all such effects.
The power of the brain over pain
Pain is weird, especially chronic pain, because it is an unreliable signal, often out of sync with biological reality — too loud, too long, too “paranoid” an alarm.8 The brain has impressive power to modulate the perception of pain, resulting in notorious and fascinating examples of surprisingly painless trauma (and the reverse, surprisingly extreme painful harmless events). But the brain can also extremely stubborn, and just because it controls pain doesn’t mean that we can control it.
But it does yield to indirect influences like reassurance, confidence, and safety. For much more on this principle, see Mind Over Pain.
This is almost certainly why the non-specific effects of therapeutic interactions loom so large in the world of therapy, probably routinely overshadowing the therapy that is being sold. Again and again, it’s not the therapy that is actually helping people, but the relationship with the therapist.
So the brain can definitely mute pain when it’s reassured and happy… and ASMR is about as good as it gets for making brains happy.
Imagine an ASMR clinic
Imagine a place where the primary goal is to trigger ASMR — or at least to create the best opportunity. Many existing clinics exist to pursue goals that are much harder to achieve, if not downright imaginary or fraudulent. ASMR may not be easy to reproduce in somehow, but at least it’s definitely a real thing.
An ASMR clinic wouldn’t have to be a massage clinic, but that seems like the ideal. It would probably specialize in luxurious massage with some specific tweaks. Making a point of speaking softly is a good example of the overlap between an ASMR trigger and just “relaxing luxury.” Optimizing the experience for relaxation almost automatically results in optimizing for ASMR triggers, but it’s a little more specialized than that. It goes a bit further.
The likelihood of triggering ASMR probably correlates strongly with how “pleasurable” the experience is, and massage therapists seem to be in a particularly good position to actually pursue that. But the clinic might well also make some other highly specific adjustments.
One thing might be especially different from traditional relaxation massage: a very focused, almost hypnotically thorough, detailed, earnest, quiet interview and a physical examination. Several attentive, questions about the patient’s current state of mind and body, and probably also asking for multiple demonstrations of movement function — just in the spirit of very curiously checking in.
I am confident that would all give me a dose of ASMR.
What’s new in this article?
Mar 12, 2022 — Editing and a few minor clarifications and additions.
2021 — Publication.
- Lochte BC, Guillory SA, Richard CA, Kelley WM. An fMRI investigation of the neural correlates underlying the autonomous sensory meridian response (ASMR). Bioimpacts. 2018;8(4):295–304. PubMed #30397584 ❐ PainSci #52158 ❐ This study showed that the medial prefrontal cortex (linked to social behaviors like grooming), and the secondary somatosensory cortex (linked to touch) were busier during tingling than non-tingling.
- Barratt EL, Spence C, Davis NJ. Sensory determinants of the autonomous sensory meridian response (ASMR): understanding the triggers. PeerJ. 2017;5:e3846. PubMed #29018601 ❐ PainSci #52155 ❐
- Valtakari NV, Hooge IT, Benjamins JS, Keizer A. An eye-tracking approach to Autonomous sensory meridian response (ASMR): The physiology and nature of tingles in relation to the pupil. PLoS One. 2019;14(12):e0226692. PubMed #31877152 ❐ PainSci #51973 ❐
“Non-specific effects” are the unintended side benefits of any kind of treatment, mostly consisting of bedside manner, which are always involved in any kind of healthcare. Their potency is generally underestimated. These are contrasted with the specific effect of a treatment method, the “active ingredient,” which allegedly has benefits that can only occur when that treatment is used — and the potency of specific effects is usually over-estimated. They are often less important than all the ritual, meaning, and social engagement that are delivered with them. People often give credit to the treatment when it’s really the non-specific effects that did the heavy lifting.
For instance, if a physical therapist provides a patient with Cold Laser Therapy Reviewed, the lasers are the “active ingredient,” believed (probably unwisely) to have an effect on tissues that is unique and specific to that therapy. But that therapist is also delivering, consciously or unconsciously, many other things that are not unique to laser therapy: everything from the speed of their speech to the temperature of the room to the cost of the session. Many of these non-specific effects are bundled together by the concept of “beside manner,” but there’s definitely more to it than that.
- Poerio GL, Blakey E, Hostler TJ, Veltri T. More than a feeling: Autonomous sensory meridian response (ASMR) is characterized by reliable changes in affect and physiology. PLoS One. 2018;13(6):e0196645. PubMed #29924796 ❐ PainSci #52152 ❐
- Reddy NV, Mohabbat AB. Autonomous sensory meridian response: Your patients already know, do you? Cleve Clin J Med. 2020 Nov;87(12):751–754. PubMed #33229391 ❐
- Not all quackery is obvious — not even to skeptics. “Pseudo-quackery” appears to be mainstream, advanced, technological, “science-y,” or otherwise legit — quackery without any sign of being way out in left field. It has enough superficial plausibility to persist in the absence of evidence against it. This subtler type of snake oil is a more serious problem in musculoskeletal health care, because it hides right in the mainstream. For instance, it’s nearly synonymous with the early history of physical therapy, and remains alarmingly prevalent in that profession. So pseudo-quackery is extremely common, and generates more false hopes and wasted time, energy, money, and harm than more overt quackery, which is relatively marginalized. See Pseudo-Quackery in the Treatment of Pain: The large, dangerous grey zone between evidence-based care and overt quackery in musculoskeletal and pain medicine.
- Modern pain science shows that pain is as hard to predict or control as the weather, a function of countless chaotic variables, surprisingly disconnected from seemingly “obvious” causes of pain. Pain is jostled by many systemic variables, but especially by the brain’s filters, which thoroughly “tune” pain and often even overprotectively exaggerate it — so much so that sensitization can get more serious and chronic than the original problem. This has complicated all-in-your-head implications: if the brain controls all pain, does that mean that we can think pain away? Probably not, but we do have some neurological leverage — maybe we can influence pain, if we understand it. See Pain is Weird: Pain science reveals a volatile, misleading sensation that comes entirely from an overprotective brain, not our tissues.