How Does Pain Become Chronic: Understanding and Reversing the Cycle
Chronic pain is not just a physical condition; it’s also a learned pattern in the brain. Similar to how we can learn to play the piano or speak a language with practice, our brain can, unfortunately, also learn to produce pain.
How the Brain Learns Pain
Repeated activation of pain signals strengthens neural connections in the brain, making the pain response more efficient over time7. This process, called central sensitization, can cause the nervous system to become overly responsive, leading to heightened sensitivity and long-lasting symptoms.
In one ground-breaking study, researchers looked only at brain scans to predict which patients would recover from back pain and which would develop chronic pain2. Increased connectivity between the nucleus accumbens and the prefrontal cortex was a strong predictor. This suggests that our brain’s response to pain plays a huge role in whether pain fades or lingers3.
The Nervous System’s Response to Pain
When pain strikes, many of us enter a state of nervous system dysregulation. This can show up in four main patterns:
- Fight: frustration, anger, pushing through, over-fixing
- Flight: fear, anxiety, hypervigilance, constant seeking of help
- Fawn: people-pleasing, perfectionism, self-pressure
- Freeze: despair, shutdown, helplessness, emotional numbing
These stress responses can reinforce pain signals, creating a feedback loop that keeps the pain cycle going. We call this feedback loop The Sensitization Cycle.
Fear and the Amplification of Pain
Two studies demonstrate how fear and perception can amplify pain:
- The Scary Picture Study4 showed that people experienced more pain, and even felt pain without a stimulus, when viewing frightening images.
- The Pain-Related Fear Study6 found that individuals with more fear about their pain were more likely to still have pain six months later.
These findings highlight a critical truth: pain is not always a direct reflection of tissue damage, it’s deeply connected to emotional and cognitive factors.
Breaking the Cycle: Evidence-Based Therapies
At Pain Psychotherapy, our goal is to help you shift out of the sensitization cycle and into the desensitization cycle, teaching the brain and body to feel safe again.
We utilize the following two therapy approaches, along with several others, to support clients in entering the desensitization cycle to heal their chronic pain or illness.
Pain Reprocessing Therapy (PRT)
In a landmark clinical trial, 98% of people receiving PRT reported pain reduction, and 66% became pain-free or nearly pain-free, even after an average of 10.7 years of treatment-resistant chronic back pain1. Brain scans showed reduced activity in pain-related brain areas.
Emotional Awareness and Expression Therapy (EAET)
In a study of 230 people with fibromyalgia, EAET significantly reduced widespread pain, with 22.5% of participants experiencing at least a 50% reduction in pain5. By helping clients identify and express emotions safely, EAET calms the nervous system and reduces pain.
Are You Ready to Heal?
Book in for a free 20-minute consultation with one of our therapists to begin your healing journey:
Ashar, Y. K., Gordon, A., Schubiner, H., Uipi, C., Knight, K., Anderson, Z., ... & Wager, T. D. (2021). Effect of pain reprocessing therapy vs placebo and usual care for patients with chronic back pain: A randomized clinical trial. JAMA Psychiatry, 78(11), 1–11.
Baliki, M. N., Petre, B., Torbey, S., Herrmann, K. M., Huang, L., Schnitzer, T. J., ... & Apkarian, A. V. (2012). Corticostriatal functional connectivity predicts transition to chronic back pain. Nature Neuroscience, 15(8), 1117–1119.
Gordon, A., & Ziv, M. (2021). The role of the brain in chronic pain. Pain Medicine, 22(2), 281–289.
Kirwilliam, S. S., & Derbyshire, S. W. G. (2008). Increased bias to report heat or pain following emotional priming with fear. Pain, 137(1), 60–65.
Lumley, M. A., Schubiner, H., Lockhart, N. A., Kidwell, K. M., Harte, S. E., Clauw, D. J., & Williams, D. A. (2017). Emotional awareness and expression therapy, cognitive-behavioral therapy, and education for fibromyalgia: A cluster-randomized controlled trial. Pain, 158(12), 2354–2363.
Picavet, H. S., Vlaeyen, J. W., & Schouten, J. S. (2002). Pain catastrophizing and kinesiophobia: Predictors of chronic low back pain. American Journal of Epidemiology, 156(11), 1028–1034.
Song, Q., Zhang, X., & Liang, Y. (2024). Neural mechanisms of chronic pain sensitization. Neuroscience Bulletin, 40(3), 211–223.
How Pain Becomes a Conditioned Response
By Alex Klassen MSW, RSW
Our brain is a learning machine that quickly develops associations, meaning we connect conditions and responses as we move through the world. To understand how this works, we can think back to Pavlov’s research on the brain and learning, where he experimented with dogs. Right before feeding his dogs, Pavlov started turning on a clicking metronome. After a few trials, he noticed the dogs started salivating from the sound of the metronome alone. The dogs developed a conditioned response1.
The condition: the sound of a metronome
The response: salivation
When we’re experiencing chronic pain, it’s easy for the brain to make an association between an activity or stimuli (the “condition”) and pain (the “response”). For example, imagine a woman notices her back pain increasing when sitting in her computer chair. Naturally, her brain asks the question, “Why does my back hurt?”. And the most obvious answer might be, “It’s this stupid chair!”. If there was a problem with the chair and it was hurting her back, this association is helpful. She might fix the problem by adjusting the chair, buying a better one, stretching more, changing her posture, getting a massage, or avoiding sitting for long periods of time.
Making associations is essential for learning and survival, but the brain can make mistakes. Let’s imagine instead this woman’s pain is neuroplastic, meaning it is caused by her brain mistaking safe nerve signals from the body as dangerous2. In this scenario, the trigger of her back pain is actually a stressor like her job, or some other cognitive or emotional problem occurring2,3. In this case, the conditioned response connecting her pain to the chair is unhelpful. Rather than helping the woman address her stress and emotions, the pain sensations may send her down the wrong road, fixating instead on problems with her chair and back.
The condition: sitting in the computer chair
The response: back pain
If the woman believes the chair was the cause of her pain, her brain is more likely to generate more pain the next time she sits in it. This is because pain is a danger signal, it’s job it to protect you from things it believes to be dangerous2. This can lead to the conditioned response growing stronger and stronger.
Conditioned responses can happen all over the place, including foods, weather, time of day, stress, emotions, smells, environments, and certain movements and activities. This often leads to more and more avoidance behaviours, increased fear in our bodies, and life getting smaller and smaller. It’s a nasty feedback loop, but it’s possible to reverse it.
When working with our clients, we gather evidence for physical safety, while providing education on how neuroplastic pain works. Through this process, our clients often realize their brain is being over-protective, producing pain in many conditioned responses where it doesn’t need to. Recognizing how neuroplastic pain is occurring as part of a conditioned response allows our clients to feel safer and make changes. Step by step, we can teach our brain that our body is a lot safer than it used to think, changing our beliefs and gradually re-engaging in activities and environmental stimuli. Over time, this leads to less pain and a fuller life, which are the goals we work toward with every client.
Book a free 20-minute consultation with one of our therapists and begin your journey out of chronic pain today.
Rehman I, Mahabadi N, Sanvictores T, et al. (2023). Classical Conditioning. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
Gordon, A., Ziv, A. (2021). The way out: A revolutionary, scientifically proven approach to healing chronic pain. Sony/ATV Music Publishing LLC.
Crofford LJ. Chronic Pain: Where the Body Meets the Brain. Trans Am Clin Climatol Assoc. 2015;126:167-83. PMID: 26330672; PMCID: PMC4530716.