The more pain you expect, the more you feel, new study shows
Expect a shot to hurt and it probably will, even if the needle poke isnât really so painful. Brace for a second shot and youâll likely flinch again, even thoughâsecond time aroundâyou should know better.
Thatâs the takeaway of a new brain imaging study by CU Boulder neuroscientists which found that expectations about pain intensity can become self-fulfilling prophecies. Surprisingly, those false expectations can persist even when reality repeatedly demonstrates otherwise, the study found.
âWe discovered that there is a positive feedback loop between expectation and pain,â said psychology and neuroscience professor Tor Wager, senior author of the paper published in Nature Human Behaviour. âThe more pain you expect, the stronger your brain responds to the pain. The stronger your brain responds to the pain, the more you expect.â
Pain can be a self-fulfilling prophecy
For decades, researchers have been intrigued with the idea of self-fulfilling prophecy, with studies showing expectations can influence everything from how one performs on a test to how one responds to a medication. The new study is the first to unpack the vicious cycle between increased pain expectations and increased pain and elucidate the neural mechanisms underlying it.
Marieke Jepma, then a postdoctoral researcher in Wagerâs lab, launched the research after noticing that even when test subjects were shown time and again that something wouldnât hurt badly, some still expected it to.
âWe wanted to get a better understanding of why pain expectations are so resistant to change,â said Jepma, lead author of the study and now a researcher at the University of Amsterdam.
The researchers recruited 34 subjects and taught them to associate one symbol with low heat and another with high, painful heat.
Then, the subjects were placed in a functional magnetic resonance imaging (fMRI) machine, which measures blood flow in the brain as a proxy for neural activity. For 60 minutes, subjects were shown low or high pain cues (the symbols, the words Low or High, or the letters L and W), then asked to rate how much pain they expected.
Then varying degrees of painful but non-damaging heat were applied to their forearm or leg, with the hottest reaching âabout what it feels like to hold a hot cup of coffeeâ Wager explains.
Then they were asked to rate their pain.
Unbeknownst to the subjects, heat intensity was not actually related to the preceding cue.
The study found that when subjects expected more heat, brain regions involved in threat and fear were more activated as they waited. Regions involved in the generation of pain were more active when they received the stimulus. Participants reported more pain with high-pain cues, regardless of how much heat they actually got.
âThis suggests that expectations had a rather deep effect, influencing how the brain processes pain,â said Jepma.
âConfirmation biasâ applies to pain too
Surprisingly, their expectations also highly influenced their ability to learn from experience. Many subjects demonstrated high âconfirmation biasââthe tendency to learn from things that reinforce our beliefs and discount those that donât. For instance, if they expected high pain and got it, they might expect even more pain the next time. But if they expected high pain and didnât get it, nothing changed.
âYou would assume that if you expected high pain and got very little you would know better the next time. But interestingly, they failed to learn,â said Wager.
This phenomenon could have tangible impacts on recovery from painful conditions, suggests Jepma.
âOur results suggest that negative expectations about pain or treatment outcomes may in some situations interfere with optimal recovery, both by enhancing perceived pain and by preventing people from noticing that they are getting better,â she said. âPositive expectations, on the other hand, could have the opposite effects.â
The research also may shed light on why, for some, chronic pain can linger long after damaged tissues have healed.
Whether in the context of pain or mental health, the authors suggest that it may do us good to be aware of our inherent eagerness to confirm our expectations.
âJust realizing that things may not be as bad as you think may help you to revise your expectation and, in doing so, alter your experience,â said Jepma.
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