Pain is your brain’s opinion. And opinions can be influenced.

Pain is one of the most universal human experiences. And yet most of us misunderstand what it is. We think of pain as a direct consequence of an injury. But it’s actually a far more complex process, because the brain also plays a role in the experience of pain. In this article, I focus on the neuropsychological side of pain: how the brain shapes it, what makes it worse, and what you can do about it.

Pain is an alarm system:

The purpose of pain is to be a “protective alarm system” that makes you aware of an injury that requires your help or tending [1]. Because pain demands your attention, you stop what you are doing, get help, take medicine and take action to prevent further damage to your body. Just imagine not feeling any pain - you would probably keep going without tending to injuries, and mild injuries would quickly turn into serious ones. 

How pain works: 

Pain involves many different mechanisms. To focus on what’s relevant here, it can be summarised like this: Let’s say you have a small injury. There is a signal from your injury going to your brain reporting: “something is damaged here and it requires your attention!”. Multiple brain areas and pathways are then involved to process this input, and to create the sensation of pain [2]. How much pain your brain makes you feel is based on the input that comes in from the injury, how much of a threat the injury seems to pose, and psychological factors like: attention, mood, thoughts and expectations.

A visualization:
Imagine a child tripping and scraping their knee a little bit. If the child is well-rested, playing with friends, and happily eating an ice cream, they might cry for a moment but move on quickly. The same child, when tired, alone, or already upset, may experience that same bump as much more painful. The pain would feel completely different for the child, although the injury is the same. This is because the child was in a different psychological state and context. 

What makes pain feel even worse?

Research has identified that your mood, attention and expectations have an impact on how much pain you will feel after an injury. Specifically, directing your attention towards the injury and pain (instead of being distracted) can make the pain worse [3]. If you are in a bad mood you will experience the same injury as more painful than if you were in a good mood [4]. Finally, your expectations of how much something will hurt or how well a medicine will work can influence what you actually experience [5]. If you expect something to hurt severely, you are more likely to actually experience it as severe pain. The brain prepares for what it expects, and amplifies or dampens signals accordingly [6]. Fun fact: Negative expectations of pain medicine (thinking it won’t work) can literally undo the pain-relieving effect of remifentanil - a strong opioid pain killer. And having positive expectations can double the effectiveness of remifentanil [7]! (Re-read that and let it sink in! It is crazy that your mind can have such a large effect on what you experience.)

Something I learned about when I wanted to become a midwife is the “fear - tension - pain cycle”. When experiencing pain, your body might be in a fight or flight state and you may feel afraid or worried. You may also notice that your body is carrying a lot of tension. For example, in your shoulders, jaw, or around the source of pain. If you are afraid, your muscles naturally get more and more tense [8]. Tense muscles restrict blood flow to the area, trigger the release of inflammatory chemicals and make the surrounding nerves more sensitive [9]. It’s as if you turn up the volume of the pain signal going to the brain. The problem is that as your pain gets more intense, you might feel even more stressed out, which can cause even more muscle tension… you get it, it’s a vicious circle.

To keep it simple: your thoughts, mood, attention and muscle tension can all affect how your brain processes and creates the sensation of pain. 

Disclaimer: 

Since this may be the first time you are reading this, it’s important to understand that this is not meant to make you feel guitly or to say that you are causing your own pain. Pain is an extremely complex experience, and can be very difficult to deal with (especially if you are already feeling stressed or afraid). Pain is something you cannot completely control, but can influence. The idea of this article is to help you understand pain better, so you can learn how to manage the pain better - not to make you feel even worse about feeling pain.

What can reduce your pain?

Most people have experienced that emotions and their environment can influence pain - for example, the really bad ear pain that seems to disappear the second you arrive at your GP’s office, or the headache that stops once a family member arrives back home. Your brain may have interpreted that help is here, and the threat is being handled.

Pain can be reduced by working with the process described earlier. Essentially: Relaxation, good mood, distraction, positive expectations for pain relief, and feeling safe can all help you feel less pain [10]. Right now, you may be thinking “how am I supposed to feel happy and relaxed while experiencing pain? It’s the last thing I feel like feeling.” - fair enough. When feeling low, trying to get yourself to feel positive probably feels fake.

Here’s an overview of what could be adding to or decreasing your pain:

The next time you experience pain: reflect on which factors might be playing a role in your pain. Are you currently more on the side of “increasing pain” or “decreasing pain”? What is going well right now, and what might be contributing to the pain right now? 

Instead of telling yourself to feel better, you can try taking specific steps that might shift you into a more positive, relaxed and distracted state naturally. It can help to try out what works for you, and create a mental list of things you can do when experiencing pain. Unfortunately, these tips will likely not make all your pain disappear, but they can definitely help. And I believe it is especially worth looking into and thinking about if you have chronic pain.

What can you do if you notice that you are stressed, tense or catastrophising?

1. Breathing: 

   You can try breathing more deeply, and breathing out longer than you breathe in. There are plenty of YouTube and Spotify audios that can guide your breathing. Slow breathing, specifically with a shorter inhalation and longer exhalation, can reduce pain. This works partly by activating the parasympathetic nervous system (the rest and recover state) which reduces pain signals [11].

2. Progressive muscle relaxation:

   Firstly, take some time to get into a comfortable position, where your muscles can relax. Pick a part of your body that feels tense (such as your hands, stomach or forehead). For around 5 seconds purposefully tense the muscles and then let go and relax that muscle group as much as possible. You can do this a few times, until the muscles feel relaxed. Then you can move onto the next muscle group. For this there are also YouTube videos that can guide you. Specifically the contrast between tension and releasing seems to be effective in relaxing deeply. Progressive muscle relaxation has been found to reduce anxiety and pain [12].

3. Changing your environment:

   Since you are experiencing pain and it is already interrupting your day, you might as well make your surroundings as comfortable as possible. Take pain killers if needed, use a hot water bottle, and get into a position where you can actually relax your muscles. You can do something that distracts you, like eating, putting on music, watching a movie or doing some kind of low intensity activity. Maybe it can even be nice to call someone who can help you in this moment. Don't make yourself suffer more than you need to - the goal is: comfort, muscle relaxation and distraction- three things your brain needs to turn down the volume of the pain. 

4. Social connection:

   Reaching out to someone you trust, whether it’s a text, a call or simply having someone sit with you can signal safety to your brain, and can take the edge off of the pain.

You may not be able to switch pain off entirely, but knowing that your brain is always listening means you always have some influence over it. Pain may be your brain’s opinion - but with the right tools, it’s an opinion you can nudge.

The next time you are in pain, what’s the first thing you will notice, and what’s the first thing you will try?

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References:

1. Annemarieke Flemming and Vollebregt Joke, Pijn En Het Brein - De Rol van de Hersenen Bij “Onverklaarde” Chronische Klachten (2016).

2. M. Catherine Bushnell et al., “Cognitive and Emotional Control of Pain and Its Disruption in Chronic Pain,” Nature Reviews Neuroscience (London) 14, no. 7 (2013): 502–11, https://doi.org/10.1038/nrn3516.

3. Susanna J. Bantick et al., “Imaging How Attention Modulates Pain in Humans Using Functional MRI,” Brain (Oxford) 125, no. 2 (2002): 310–19, https://doi.org/10.1093/brain/awf022.

4. Chantal Villemure and M. Catherine Bushnell, “Mood Influences Supraspinal Pain Processing Separately from Attention,” The Journal of Neuroscience (United States) 29, no. 3 (2009): 705–15, https://doi.org/10.1523/JNEUROSCI.3822-08.2009.

   Marco L. Loggia et al., “Experimentally Induced Mood Changes Preferentially Affect Pain Unpleasantness,” The Journal of Pain (United States) 9, no. 9 (2008): 784–91, https://doi.org/10.1016/j.jpain.2008.03.014.

5. Kaya J. Peerdeman et al., “An Integrative Review of the Influence of Expectancies on Pain,” Frontiers in Psychology (Switzerland) 7 (2016): 1270–1270, https://doi.org/10.3389/fpsyg.2016.01270.

6. Irene Tracey, “Getting the Pain You Expect: Mechanisms of Placebo, Nocebo and Reappraisal Effects in Humans,” Nature Medicine 16, no. 11 (2010): 1277–83, https://doi.org/10.1038/nm.2229.

7. Ulrike Bingel et al., “The Effect of Treatment Expectation on Drug Efficacy: Imaging the Analgesic Benefit of the Opioid Remifentanil,” Science Translational Medicine 3, no. 70 (2011), https://doi.org/10.1126/scitranslmed.3001244.

8. Takanori Taniguchi et al., “Relationship between Fear-Avoidance Beliefs and Muscle Co-Contraction in People with Knee Osteoarthritis,” Sensors 24, no. 16 (2024): 5137, https://doi.org/10.3390/s24165137;
   Andrew H. Rogers and Samantha G. Farris, “A Meta‐analysis of the Associations of Elements of the Fear‐avoidance Model of Chronic Pain with Negative Affect, Depression, Anxiety, Pain‐related Disability and Pain Intensity,” European Journal of Pain (London, England) 26, no. 8 (2022): 1611–35, https://doi.org/10.1002/ejp.1994.

9. Kara E. Hannibal and Mark D. Bishop, “Chronic Stress, Cortisol Dysfunction, and Pain: A Psychoneuroendocrine Rationale for Stress Management in Pain Rehabilitation,” Physical Therapy (United States) 94, no. 12 (2014): 1816–25, https://doi.org/10.2522/ptj.20130597.

10. Fabrizio Benedetti, Placebo Effects: Understanding the Mechanisms in Health and Disease (Oxford University Press, 2008), https://doi.org/10.1093/acprof:oso/9780199559121.001.0001;

    Chris Eccleston and Geert Crombez, “Pain Demands Attention: A Cognitive–Affective Model of the Interruptive Function of Pain.,” Psychological Bulletin 125, no. 3 (1999): 356–66, 1999-13573-003, https://doi.org/10.1037/0033-2909.125.3.356;

    Katja Wiech, “Deconstructing the Sensation of Pain: The Influence of Cognitive Processes on Pain Perception,” Science 354, no. 6312 (2016): 584–87, https://doi.org/10.1126/science.aaf8934.

    Hunter G. Hoffman et al., “Modulation of Thermal Pain-Related Brain Activity with Virtual Reality: Evidence from fMRI,” Neuroreport (Hagerstown, MD) 15, no. 8 (2004): 1245–48, https://doi.org/10.1097/01.wnr.0000127826.73576.91.

11. Xiaoyu Jiang et al., “Effects of Breathing Exercises on Chronic Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” Journal of Back and Musculoskeletal Rehabilitation 37, no. 1 (2024): 13–23, https://doi.org/10.3233/BMR-230054;

    Hassan Jafari et al., “Can Slow Deep Breathing Reduce Pain? An Experimental Study Exploring Mechanisms,” The Journal of Pain 21, nos. 9–10 (2020): 1018–30, https://doi.org/10.1016/j.jpain.2019.12.010;

    Satin L. Martin et al., “Respiration-Induced Hypoalgesia: Exploration of Potential Mechanisms,” The Journal of Pain 13, no. 8 (2012): 755–63, https://doi.org/10.1016/j.jpain.2012.05.001.

12. Yasemin Ozhanli and Nuray Akyuz, “The Effect of Progressive Relaxation Exercise on Physiological Parameters, Pain and Anxiety Levels of Patients Undergoing Colorectal Cancer Surgery: A Randomized Controlled Study,” Journal of Perianesthesia Nursing (United States) 37, no. 2 (2022): 238–46, https://doi.org/10.1016/j.jopan.2021.08.008.