How Pain Becomes a Conditioned Response

 
How can Pain Become a Conditioned Response? - Pain Psychotherapy Canada.png

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.

 

  1. Rehman I, Mahabadi N, Sanvictores T, et al. (2023). Classical Conditioning. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.

  2. Gordon, A., Ziv, A. (2021). The way out: A revolutionary, scientifically proven approach to healing chronic pain. Sony/ATV Music Publishing LLC.

  3. Crofford LJ. Chronic Pain: Where the Body Meets the Brain. Trans Am Clin Climatol Assoc. 2015;126:167-83. PMID: 26330672; PMCID: PMC4530716.

 

What Causes Neuroplastic Pain?

 

By Tanner Murtagh MSW, RSW

Many forms of chronic pain and symptoms are not the result structural damage or systemic diseases, but occur due to a rewiring of the brain and nervous system1,2,3. This is known as neuroplastic pain. Neuroplastic pain is triggered and perpetuated when the danger circuits in our brains become over-activated and our nervous systems are chronically dysregulated4,5.


Neuroplastic pain can develop in the following ways:

  1. Initial Injury
  2. Perceived Injury
  3. Stressful Situations or Life Transitions
  4. Trauma and Childhood Adversity
  5. Depression, Anxiety, or Obsessive Thinking
  6. Common Maladaptive Coping Mechanisms
  7. Feeling Unsafe in Your External World

  1. Initial Injury

    Neuroplastic pain can begin with a structural injury4. Typically, physical injuries heal within a few weeks to a few months, as our body is designed to heal. However, after an injury has healed the brain may maintain the neural pathways associated with the pain because the brain has learned to produce pain to protect you6. These learned neural pathways can be triggered and perpetuated by fear, difficult emotions and nervous system dysregulation, causing pain to continue long after an injury has healed4.


  2. Perceived Injury

    When in chronic pain, our primary fear is, “there is something wrong with my body”4. However, sometimes we incorrectly perceive an injury or believe our body is damaged. Research on pain and the brain shows us that, in absence of physical damage, fearing our body is damaged and expecting pain can trigger, amplify, and maintain pain in the brain7,8,9. At our clinic we frequently witness how fear and belief the body is damaged is enough to trigger pain, even when a client’s body is healthy.


  3. Stressful Situations or Life Transitions

    Stressful situations and life transitions, even positive ones, can trigger neuroplastic pain3,4. Events such as divorce, unemployment, going to university, having a baby, starting a new job, living through the pandemic, and experiencing the death of loved one can all cause difficult emotions and dysregulation in our nervous system. This can result in neuroplastic pain, as the brain triggers pain as a protective mechanism when the nervous system senses danger2. Pain being produced due to perceived danger is a normal survival response and a common part of being a human being.


  4. Trauma and Childhood Adversity

    Trauma can cause the brain and nervous system to become chronically dysregulated, which includes responses of fight, flight, freeze, or shutdown5. Trauma and adverse childhood experiences increase the likelihood of chronic pain developing10,11. In fact, adults are 2.7 times more likely to develop chronic widespread pain if they have significant trauma in their past, and 4 times more likely to develop chronic fatigue syndrome10,12. The connection between trauma and chronic pain and symptoms makes sense, as trauma causes our nervous system to function in a more reactive state that more readily perceives danger.


  5. Depression, Anxiety, or Obsessive Thinking

    Depression, anxiety, and obsessive thinking are signs that the nervous system is dysregulated and functioning in survival mode5,13. In our brain, the amygdala, posterior insula, anterior insula, anterior cingulate cortex, and mid cingulate cortex are involved in producing pain, emotions, anxiety, and depression14. When we are experiencing mental health concerns, both emotional pain and physical pain sensations can be produced, as shared brain regions are responsible for both14.


  6. Common Maladaptive Coping Mechanisms

    People with neuroplastic pain commonly engage in maladaptive coping mechanisms, which include perfectionism, conscientiousness, and people pleasing4. These coping mechanisms typically helped us create safety at some point in our lives, but as life changes, living this way can make us prone to self-criticism, worrying, and placing pressure on ourselves4. Over time, these coping mechanisms can cause chronic nervous system dysregulation, making us prone to developing chronic pain and symptoms.


  7. Feeling Unsafe in Your External World

    Studies have shown that social factors such as poverty, isolation, abusive or toxic relationships, race, gender and sexual orientation influence the likelihood of chronic pain developing and persisting15,16,17. Social experiences of violence, abuse, and oppression can cause us to feel unsafe in our communities and environments. “Pain is a danger signal”, and when we feel unsafe in our external world, neuroplastic pain can be triggered and perpetuated3,4.


As you can see, there are many ways neuroplastic pain can be triggered and perpetuated, unique to each person. The first step is assessment; as we gather evidence the pain is neuroplastic in nature, we can begin healing the pain at a brain and nervous system level. At our clinic we provide effective, evidence-based treatment to support our clients in reducing or eliminating their chronic pain.


Book a free 20-minute consultation with one of our therapists and begin your journey out of chronic pain today.

 

  1. Woolf C. J. (2011). Central sensitization: implications for the diagnosis and treatment of pain. Pain, 152(3 Suppl), S2–S15. https://doi.org/10.1016/j.pain.2010.09.030

  2. Clarke, D. D., & Schubiner, H. (2019). Introductions. In D. Clarke, H. Schubiner, M. Clarke-Smith, & A. Abbass (Eds.), Psychophysiologic disorders: Trauma informed, interprofessioal diagnosis and treatment (pp. 5-25). Psychophysiologic Disorders Association.

  3. Gordon, A., Ziv, A. (2021). The way out: A revolutionary, scientifically proven approach to healing chronic pain. Sony/ATV Music Publishing LLC.

  4. Pain Reprocessing Therapy Center (2021). Pain reprocessing therapy training.

  5. Dana, D. (2018). The polyvagal theory in therapy: Engaging the rhythm of regulation. WW Norton & Co.

  6. Hanscom, D. (2019). Making the right choice about spine surgery. In D. Clarke, H. Schubiner, M. Clarke-Smith, & A. Abbass (Eds.), Psychophysiologic disorders: Trauma informed, interprofessioal diagnosis and treatment (pp. 83-98). Psychophysiologic Disorders Association.

  7. Castro, W. H., Meyer, S. J., Becke, M. E., Nentwig, C. G., Hein, M. F., Ercan, B. I., Thomann, S., Wessels, U., & Du Chesne, A. E. (2001). No stress--no whiplash? Prevalence of "whiplash" symptoms following exposure to a placebo rear-end collision. International journal of legal medicine, 114(6), 316–322. https://doi.org/10.1007/s004140000193

  8. Bayer, T. L., Baer, P. E., & Early, C. (1991). Situational and psychophysiological factors in psychologically induced pain. Pain, 44(1), 45–50. https://doi.org/10.1016/0304-3959(91)90145-N

  9. 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. https://doi.org/10.1093/aje/kwf136

  10. Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., Dube, S. R., & Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. European archives of psychiatry and clinical neuroscience, 256(3), 174–186. https://doi.org/10.1007/s00406-005-0624-4

  11. Green, C. R., FloweValencia, H., Rosenblum, L., & Tait, A. R. (2001). The role of childhood and adulthood abuse among women presenting for chronic pain. The Clinical Journal of Pain 17, 359-364.

  12. Afari, N., Ahumada, S. M., Wright, L. J., Mostoufi, S., Golnari, G., Reis, V., & Cuneo, J. G. (2014). Psychological trauma and functional somatic syndromes: a systematic review and meta-analysis. Psychosomatic medicine, 76(1), 2–11. https://doi.org/10.1097/PSY.0000000000000010

  13. Dana, D. (2019). 2-Day Workshop: Polyvagal Theory Informed Trauma Assessment and Interventions

  14. Schubiner, H. & Kleckner, I. (2019). Introductions. In D. Clarke, H. Schubiner, M. Clarke-Smith, & A. Abbass (Eds.), Psychophysiologic disorders: Trauma informed, interprofessioal diagnosis and treatment (pp. 5-25). Psychophysiologic Disorders Association. 

  15. Mills, S. E. E., Nicolson, K. P., & Smith, B. H. (2019). Chronic pain: a review of its epidemiology and associated factors in population-based studies. British journal of anaesthesia, 123(2), e273–e283. https://doi.org/10.1016/j.bja.2019.03.023

  16. Schubiner, H., Jackson, B., Molina, K. M., Sturgeon, J. A., Sealy-Jefferson, S., Lumley, M. A., Jolly, J., & Trost, Z. (2023). Racism as a Source of Pain. Journal of general internal medicine, 38(7), 1729–1734. https://doi.org/10.1007/s11606-022-08015-0

  17. Zajacova, A., Grol-Prokopczyk, H., Liu, H., Reczek, R., & Nahin, R. L. (2023). Chronic pain among U.S. sexual minority adults who identify as gay, lesbian, bisexual, or "something else". Pain, 164(9), 1942–1953. https://doi.org/10.1097/j.pain.0000000000002891