Learned pain as a leading cause of chronic pain

Epistemic status: Amateur synthesis of medical research that is still recent but now established enough to make it into modern medical textbooks. Some specific claims vary in evidence strength. I’ve spent ~20-30 hours studying the literature and treatment approaches, which were very effective for me.

Disclaimer: I'm not a medical professional. This information is educational only, not medical advice. Consult healthcare providers for medical conditions.

Key claims

This post builds on previous discussions about the fear-pain cycle and learned chronic pain. The post adds the following claims:

1. Neuroplastic pain - pain learned by the brain (and/or spinal cord) - is a well-evidenced phenomenon and widely accepted in modern medical research (very high confidence).
2. It explains many forms of chronic pain previously attributed to structural causes - not just wrist pain and back pain (high confidence). Other conditions include everything from pain in the knees, pelvis, bowels, neck, and the brain itself (headaches). Some practitioners also treat chronic fatigue (inc. Long-COVID), dizziness and nausea in a similar way but I haven't dug into this.
3. It may be one of the most common or even the single most common cause of chronic pain (moderate confidence).
4. There are increasingly useful resources, studied treatments with very large reported effect size, and trained practitioners.
5. Doctors are often unaware that neuroplastic pain exists because the research is recent and not their specialty. They often attribute it to tissue damage or structural causes like minor findings in medical imaging and biomechanical or blood diagnostics, which often fuels the fear-pain cycle.

My personal experience with with chronic pains and sudden relief

My first chronic pain developed in the tendons behind my knee after running. Initially manageable, it progressed until I couldn't stand or walk for more than a few minutes without triggering days of pain. Medical examinations revealed inflammation and structural changes in the tendons. The prescribed treatments—exercises, rest, stretching, steroid injections—provided no meaningful relief.

Later, I developed unexplained tailbone pain when sitting. This quickly became my dominant daily discomfort. Specialists at leading medical centers identified a bone spur on my tailbone and unanimously concluded it was the cause. Months later, I felt a distinct poking sensation near the bone spur site, accompanied by painful friction when walking. Soon after, my pelvic muscles began hurting, and the pain continued spreading. Steroid injections made it somewhat more tolerable, but despite consulting multiple specialists, the only thing that helped was carrying a specially shaped sitting pillow everywhere.

None of these pains appeared psychosomatic to me or to my doctors. The sensations felt physically specific and emerged in plausible patterns that medical professionals could link to structural abnormalities they observed in imaging.

Yet after 2-3 years of daily pain, all of these symptoms largely disappeared within 2 months. For reasons I'll touch on below, it was obvious that the improvements resulted from targeted psychological approaches focused on 'unlearning' pain patterns.  This post covers these treatments and the research supporting them.

For context, I had already written most of this post before applying most of these techniques to myself. I had successfully used one approach (somatic tracking) for my pelvic pain without realizing it was an established intervention.

What is neuroplastic (learned) pain?

Consider two scenarios:

1. You touch a hot stove and immediately feel pain
2. You develop chronic back pain that persists for years despite no clear injury

Both experiences involve the same neural pain circuits, but they serve different functions. The first is a straightforward protective response. The second represents neuroplastic pain - pain generated by the brain as a learned response rather than from ongoing tissue damage.

This might pattern-match to "it's all in your head," but that's a bit of a misunderstanding. All pain, including from obvious injuries, is created by the brain. The distinction is whether the pain represents: a) An accurate response to tissue damage b) A learned neural pattern that persists independently of tissue state.

Strength of evidence

The overall reality of neuroplastic pain as a common source of chronic pain has a broad evidence base. I haven't dug deep enough to sum it all up, but there are some markers of scientific consensus:

• In 2019, the WHO added "nociplastic pain" (another word for neuroplastic pain) as an official new category of pain, alongside the long established nociceptic and neuropathic pain categories^[1]
• Papers in top journals or with thousands of citations (‘central sensitization’ is another word for neuroplastic pain)
• Inclusion in modern medical textbooks and curricula (as stated by a contact who currently studies medicine)

Side note: With obvious caveats, LLMs think that there is strong evidence for neuroplastic pain and various claims related to it^[2].

Why we learn pain

(This part has the least direct evidence, as it’s hard to test.)

Pain is a predictive process, not just a direct readout of tissue damage. Seeing the brain as a Bayesian prediction machine, it generates pain as a protective output when it predicts potential harm. This means pain can be triggered by a false expectation of physical harm.

From an evolutionary perspective, neuroplastic pain confers significant advantages:

1. False Positive Bias: Mistakenly producing pain when no damage exists (false positive) is less costly than failing to produce pain when damage does exist (false negative). Perhaps this is part of the reason why people with anxious brains, which tend to focus more on threats, are more prone to neuroplastic pain.
2. Predictive Efficiency: The brain generates pain preemptively when contextual cues suggest potential danger. This is especially protective when engaging in an activity that has caused (perceived) damage in the past.

As Moseley and Butler explain, pain marks "the perceived need to protect body tissue" rather than actual tissue damage. This explains why fear amplifies pain: fear directly increases the brain's estimate of threat, creating a self-reinforcing loop where:

1. The brain detects a plausibly threatening sensation and generates mild pain
2. We become afraid this pain signals tissue damage (often due to prior experience or general anxiety)
3. This fear directly increases the brain's threat assessment and attention to the sensations
4. The brain produces more pain as a protective response
5. Increased pain confirms our fear, amplifying it and repeating the cycle

This cycle can also be explained in terms of predictive processing.

In chronic pain, the system becomes "stuck" in a high-prior, low-evidence equilibrium that maintains pain despite absence of actual tissue damage. This mechanism also explains why pain-catastrophizing and anxiety so strongly modulate pain intensity.

Note: Fear is broadly defined here, encompassing any negative emotion or thought pattern that makes the patient feel less safe.

Diagnosing neuroplastic pain

The following patterns suggest neuroplastic pain, according to Alan Gordon’s book The Way Out. Each point adds evidence. Patients with neuroplastic pain will often have 2 or more. But some patients have none of them, or they only begin to show during treatment.

• Pain started or intensified during a time of stress (but may continue after stress subsides)
• Pain originated without injury (or the injury should have healed a long time ago)
• Multiple or many symptoms or locations
• Symptoms are inconsistent
• Symptoms spread, move, or change qualitatively
• Symptoms triggered by stress or emotional challenge
• Triggers (increasing or reducing pain) that have nothing to do with your body
• Symmetrical symptoms (e.g. in the left and right knee, this is strong evidence against injury)
• Delayed pain that increases after the triggering activity finished
• Childhood adversity
• High in any of these personality traits: self-criticism, pressure, worrying and anxiety, perfectionism, conscientiousness, people pleasing - these correlate with neuroplastic pain
• Worrying about the pain itself
• No clear physical diagnosis (noting that doctors often over-interpret minor findings in medical imaging etc, see below, because they are not aware of neurological explanations. But it is still often helpful to get these diagnostics to confirm or disconfirm neuroplastic pain.)

Some (but not many) other medical conditions can also produce some of the above. For example, systemic conditions like arthritis will often affect multiple locations (although even arthritis often seems to come with neuroplastic pain on top of physical causes).

Of course, several alternative explanations might better explain your pain in some cases - such as undetected structural damage (especially where specialized imaging is needed), systemic conditions with diffuse presentations, or neuropathic pain from nerve damage. There's still active debate about how much chronic pain is neuroplastic vs biomechanical. The medical field is gradually shifting toward a model where a lot of chronic pain involves some mixture of both physical and neurological factors, though precisely where different conditions fall on this spectrum remains contested.

Case study: my diagnosis

I've had substantial chronic pain in the hamstring tendons, tailbone, and pelvic muscles. Doctors found physical explanations for all of them: mild tendon inflammation and structural changes, a stiff tailbone with a bone spur, and high muscle tension. All pains seemed to be triggered by physical mechanisms like using the tendons or sitting on the tailbone. Traditional pharmacological and physiotherapy treatments brought partial, temporary improvements.

I realized I probably had neuroplastic pain because:

• I've had multiple unrelated chronic pains (pelvis, knee, tailbone, and, in the past, pain from typing and wearing headphones)
• One of my pains was emotionally triggered and inconsistent
• One of my pains greatly decreased under mild physical pressure, which was suspicious. And also when I was heaving a great time.
• While doctors noted physical explanations for all my pains (in MRIs), they were weak enough that they could’ve easily appeared in healthy people. I had to ask multiple doctors before they told me this.
• Symmetrical pain in both knees (strong evidence) and previously in both wrists

Finally, the most convincing evidence was that pain reprocessing therapy (see below) worked for all of my pains. The improvements were often abrupt and clearly linked to specific therapy sessions and exercises (while holding other treatments constant).

If you diagnose yourself, Gordon’s book recommends making an ‘evidence sheet’ and building a case. This is the first key step to treatment, since believing that your body is okay can stop the fear-pain cycle.

Belief barriers

Believing that pain is neuroplastic, especially on a gut level, is important for breaking the fear-pain cycle. But it is difficult for several reasons:

1. Evolutionary programming: Pain evolved specifically to make us believe something is physically wrong. This belief is feature, not a bug - it made us avoid dangerous activities.
2. Medical diagnostics: Some findings seem significant but appear commonly in pain-free individuals. For example, herniated discs (37% of asymptomatic 20-year-olds) or bulged disks, mild tendon inflammation, muscle tension, minor spine irregularities and degradation/arthritis, body asymmetries, poor posture, bone spurs, and meniscus tears. Doctors found physical reasons for all three of my chronic conditions but the conditions all went away without changing the physical findings.
3. Conditioned responses: Pain often follows predictable patterns that seem to confirm structural causes. For example, my own wrist pain increased reliably the longer I typed. This created a compelling illusion of mechanical causation, but is also common for people with neuroplastic pain because the brain fears the most plausible triggers.

Treatment Approaches

Pain neuroscience education

• Understanding pain neuroscience reduces threat perception by reducing the belief that the body is being damaged
• Multiple RCTs show education alone can reduce pain

Threat Reprocessing

• Actively engaging with pain while reframing it as safe
• Similar neural mechanisms to exposure therapy
• Applies modern psychotherapy approaches to pain: exposure therapy, mindfulness, cognitive behavioral therapy (CBT) for reframing and Acceptance and Commitment Therapy (ACT)
• Example: Somatic tracking exercises from Alan Gordon’s work
  • The patient pays curious attention to the pain while exposed to it, while reaffirming safety. The patient also reduces protective responses like shifting position because the brain can see them as a signal that something is wrong. This alone greatly improved two of my pains. Some guided exercises are available in Insight Timer.
• Handling set backs: Most patients will experience multiple relapses. It is important to handle them calmly, e.g. by using resources at the bottom of this post.

General emotional regulation and stress reduction

• Research shows clear correlations between emotional dysregulation and neuroplastic pain, both in terms of getting it initially, re-triggering it, and indicating that the pain is less likely to be resolved.
• Techniques include mindfulness meditation, cognitive behavioral therapy, and the full stack of modern psychotherapy.
• Learning emotional regulation techniques is also important for threat reprocessing around pain.

Traditional medical treatments

(Reminder that I’m not a medical professional, and this list misses many specialized approaches one can use.)

• These treatments can work, whether by changing your beliefs, triggers, or underlying physical problems that may be present on top of neuroplastic pain.
• Strength training is well-evidenced for many chronic pain conditions such as back pain and tendon pain. Exercise changes many things in the body, making it hard to know through which mechanism it works. Plausibly, it works often works by showing your brain that the body is okay, while also knowing that the medical practitioner said it is safe to exercise. Developing your own exercise program is much better than nothing (assuming you know that it is actually not dangerous to you). But I would pretty strongly recommend starting working with a physiotherapist to find an appropriate program for you and keep you accountable to it.
• Pharmacological treatments:
  • Duloxetine (an SNRI drug) is often prescribed and well tested for neuroplastic or otherwise unexplained pain. I'm not sure why it works, there are probably theories I’m unaware of, but maybe it works because it reduces anxiety.
  • Some practitioners recommend 'breaking the cycle' of chronic pain. Pain-relieving drugs can help with this. These include numbing lidocaine plasters and regular pain killers. More speculatively, topical Capsaicin may distract the nervous system.
• This list is obviously non-exhaustive.

Resources

I recommend reading a book and immersing yourself in many resources, to allow your brain to break the belief barrier on a gut level. Doing this is called pain neuroscience education (PNE), a well-tested intervention.

My recommendation: “The Way Out” by Alan Gordon. I found the book compelling and very engaging. The author developed one of the most effective comprehensive therapies available (PRT, see below).

Books

• "The Way Out" by Alan Gordon
• "Explain Pain" by Lorimer Moseley - more technical, aimed at clinicians
• Others I know less about: John Sarno’s classic books; Unlearn Your Pain by Howard Schubiner; The Body Keeps the Score (more focused on pain after trauma)

Treatment Programs

• Curable App: structured neuroplastic pain program with many exercises and educational materials, including those mentioned above)
• Pain Reprocessing Therapy (PRT, from Gordon’s book): Found to cure treatment-resistant chronic back pain for 66% of patients in an RCT. The effect size of 1.14 (hedges-g) is very unusually large for this field and mostly held up over time. The therapy combines pain neuroscience education and threat reprocessing.
• SIRPA (structured recovery approach I haven’t tried)

Therapists

• Pain Reprocessing Therapy Pracititioners - contact here for personalized recommendations.
• You should be able to find chronic pain therapists through careful searching. I haven’t explored this much.

Online Resources

• ‘Somatic Tracking’ guided audio scripts on Insight Timer - I found this extremely helpful.
• Curable Health Blog
• Thank you Dr Sarno - inspiring success stories, useful for belief change and overcoming fear

Appendix: Chronic fatigue, dizziness, nausea etc

'Central Sensitivity Syndromes' can allegedly also produce fatigue, dizziness, nausea and other mental states. I haven't dug into it, but it seems to make sense for the same reasons that neuroplastic pain makes sense. I do know of one case of Long COVID with fatigue, where the person just pretended that their condition is not real and it resolved within days. 

I’d love to hear if others have dug into this. So far I have seen it mentioned in a few resources (1, 2, 3, 4) as well as some academic papers.

It seems to make sense that the same mechanisms as for chronic pain would apply: For example, fatigue can be a useful signal to conserve energy (or reduce contact with others), for instance because one is sick. But when the brain reads existing fatigue as evidence that one is sick, this could plausibly lead to a vicious cycle where perceived sickness means there is a need for more fatigue.

1. ^{^}

   ChristianKI pointed out that the WHO's classification also includes e.g. Chinese traditional medicine. So it is worth adding that the WHO's classification of nociplastic pain was based in large part on the recognition and advocacy by the International Association for the Study of Pain (IASP) which is the leading global professional organization in pain research and medicine.

2. ^{^}

   For example, here is Claude 3.5’s assessment of how much evidence there is in specific areas:

   1. Strongest Evidence (multiple RCTs, consistent mechanistic understanding):
      • Brain imaging shows identical activation patterns between acute pain and neuroplastic pain that is experimentally induced by giving fake electric shocks etc.
      • Pain often persists unchanged despite tissue healing
      • Structural abnormalities correlate poorly with pain levels
      • WHO's official recognition of "nociplastic pain" (2019)
   2. Strong Evidence (some RCTs, strong observational data):
      • Psychotherapy approaches targeting neural patterns can cure chronic pain (as measured by both self-reports and brain imaging)
      • Stress and emotional states modulate pain intensity
      • Pain patterns often violate anatomical expectations
   3. Moderate Evidence (limited RCTs, good observational data):
      • Neuroplastic pain may be the primary cause of most chronic pain
      • Specific treatment protocols' relative effectiveness
   4. Areas of Uncertainty:
      • Optimal treatment protocols
      • Individual patient susceptibility factors