Chronic Pain and Neuroplastic Pain
Understanding pain, threat, trauma and the nervous system
Chronic pain is real pain.
But pain does not always mean that the body is being damaged.
One of the most important developments in contemporary pain science is the recognition that pain can persist even after an injury has healed, when structural findings do not adequately explain the severity of symptoms, or when the nervous system has learned to interpret otherwise safe sensations as dangerous.
This is often described as neuroplastic pain.
The related clinical term nociplastic pain refers to pain associated with altered pain processing when ongoing tissue damage or injury to the somatosensory system does not adequately explain the symptoms.
For some people, this shift in understanding can be profound.
Instead of asking only:
What is wrong with my body?
we can also begin to ask:
What has my nervous system learned to protect me from?
And, importantly:
Can it learn something different?
My work with chronic pain is informed by Pain Reprocessing Therapy (PRT), contemporary pain science, somatic approaches and my wider work with trauma, attachment, dissociation and shock.
I am particularly interested in what happens at the meeting point between pain, threat and traumatic experience.
Why pain can persist
Pain is fundamentally protective.
When we are injured, pain encourages us to withdraw, guard an affected area, rest and seek help.
But pain is not a direct measurement of tissue damage.
The nervous system continuously interprets information from the body in relation to context, previous experience, expectation, emotion and perceived threat.
When it concludes that protection is required, the experience of pain can increase.
And the nervous system learns.
After prolonged pain, an injury, illness, frightening medical experience or period of intense stress, it can become increasingly efficient at predicting danger.
A movement that was painful during an injury may continue to trigger pain after the tissues have healed.
A sensation may become associated with danger.
A particular posture, activity, place or situation can become a cue for pain.
Stress, fear and attention can intensify symptoms because they influence the nervous system's assessment of threat.
The pain is not imagined.
The alarm is genuinely being generated.
The question is whether the alarm still accurately reflects what is happening in the body now.
What can neuroplastic pain look like?
There is no single symptom that proves that pain is neuroplastic.
But certain patterns can suggest that learned nervous-system processes are contributing significantly to symptoms.
Pain may:
- fluctuate considerably without a corresponding change in physical activity;
- move, spread or appear in different parts of the body;
- become substantially stronger during stress, conflict or emotional activation;
- diminish when a person feels absorbed, connected, safe or relaxed;
- be triggered by movements or positions that are medically considered safe;
- become associated with particular places, situations or times of day;
- persist despite adequate healing of the original injury.
Some people also develop a wider pattern of sensitivity involving fatigue, headaches, gastrointestinal symptoms, sleep disturbance, cognitive fog or increased sensitivity to touch, sound, light, temperature or other sensory input.
None of these features means that symptoms are unreal.
They suggest that the nervous system itself may have become part of the mechanism generating and maintaining them.
Fear can become part of the pain cycle
Chronic pain is frightening.
When something hurts repeatedly, it is natural to monitor it.
When something hurts repeatedly, it is natural to monitor it.
Is it worse today?
Did that movement damage something?
Should I stop?
What if this never goes away?
Over time, attention can become increasingly organised around detecting danger.
Movement may be avoided.
The body may be monitored constantly.
A small sensation can begin to carry a large amount of meaning.
A small sensation can begin to carry a large amount of meaning.
This can create a self-reinforcing cycle:
sensation → prediction of danger → fear and vigilance → increased pain → stronger expectation of danger
The nervous system then receives what appears to be confirmation:
I was right. This is dangerous.
Breaking this loop is one of the central aims of Pain Reprocessing Therapy.
Pain Reprocessing Therapy
Pain Reprocessing Therapy is a psychological approach developed specifically for neuroplastic pain.
Its central idea is simple but important:
when the body is safe but the brain continues to predict danger, changing that prediction can change the experience of pain.
PRT combines pain education with experiential work that helps the nervous system update what it has learned.
One important component is somatic tracking.
One important component is somatic tracking.
Rather than monitoring a sensation anxiously to determine whether something is wrong, we bring curious and less fearful attention to it.
We might notice:
Where exactly is the sensation?
Does it move?
Is it completely constant?
What happens when I don't immediately interpret it as dangerous?
Can I experience this sensation while also recognising that I am safe?
This is not positive thinking and it is not an attempt to convince oneself that pain does not exist.
It is a form of experiential learning.
Repeated experiences of encountering sensation or movement safely can provide the nervous system with information that contradicts its previous prediction of danger.
Over time, the alarm may no longer need to fire in the same way.
What does the research on PRT show?
Research on Pain Reprocessing Therapy is encouraging.
In a randomized clinical trial involving people with primary chronic back pain, **66% of participants assigned to PRT were pain-free or nearly pain-free after treatment**, compared with 20% receiving placebo treatment and 10% receiving usual care.
The improvements remained substantial at one year.
The study also found that reductions in beliefs that pain signalled bodily damage were associated with reductions in pain, alongside measurable changes in brain responses to pain.
A five-year follow-up published in 2025 found that participants originally assigned to PRT continued to report significantly less pain than the comparison groups. Among PRT participants who completed the five-year follow-up,
55% were nearly or completely pain-free.
This is significant because the aim is not simply to become better at coping with pain.
For some people with neuroplastic pain, the pain itself can reduce substantially or resolve.
The research so far has focused particularly on primary chronic back pain, and the same outcomes cannot automatically be assumed for every chronic pain condition.
But it provides strong evidence that learned threat processes can contribute to persistent pain — and that these processes can change.
Trauma, shock and chronic pain
For some people, trauma and chronic pain are deeply intertwined.
This does not mean that everyone with chronic pain has unresolved trauma, or that every traumatic experience produces pain.
But trauma can profoundly influence how the nervous system anticipates danger.
After overwhelming experiences, the organism may become more prepared for threat: more vigilant, more reactive to bodily sensations, quicker to brace or protect, and slower to register that danger has passed.
Research consistently finds substantial overlap between chronic pain and post-traumatic stress symptoms. Hyperarousal, fear, intrusive responses and avoidance can interact with pain and contribute to its persistence.
Sometimes the connection is obvious.
Pain may begin after:
- an accident;
- an injury;
- surgery;
- a frightening medical procedure;
- a severe illness;
- or another experience in which pain and danger occurred together.
The nervous system can learn the association very quickly:
this sensation = danger
this movement = danger
this part of my body = danger
being in this position = danger
Even after tissue healing, the prediction may remain.
Fight, flight and anger
The defensive response to threat is not only fear.
The sympathetic nervous system also prepares us for active defence — to fight, escape, push away, resist or protect ourselves.
For some people this mobilisation is experienced more as fear and urgency.
For others it may have more of a fight quality: anger, bracing, muscular tension, gripping, pushing or an impulse to defend a boundary.
For others it may have more of a fight quality: anger, bracing, muscular tension, gripping, pushing or an impulse to defend a boundary.
Sometimes the body prepares intensely for action, but the action itself is impossible.
A child cannot fight back or simply leave.
A patient undergoing a frightening medical procedure may have very little possibility of moving, resisting or escaping.
During an accident or sudden injury there may be no opportunity to complete the instinctive movement of turning away, protecting oneself or getting out of danger.
In these situations, I am interested in whether some of this defensive organisation remains relevant later — as chronic bracing, muscular tension, vigilance, irritability, anger, sensitivity to bodily sensation, or a nervous system that continues to prepare for danger after the original situation has ended.
When pain itself becomes the threat
Pain can eventually become the object of the defensive response.
Living with persistent symptoms can generate frustration, anger, helplessness and sometimes a sense of betrayal by one's own body.
Sometimes this is very conscious:
I hate this pain.
Why is my body doing this to me?
I need this sensation to stop.
At other times it may appear more indirectly as bracing, irritability, tension, an urge to push the sensation away or an ongoing internal struggle against what the body is doing.
The nervous system may therefore begin responding not only to an original injury or traumatic event, but to the pain sensation itself as something that must be fought, controlled or escaped.
Another protective loop can emerge:
pain → threat → fear or anger → defensive mobilisation → increased vigilance and bodily activation → more pain
Pain, fear, anger, threat and defensive mobilisation can become organised within the same protective system.
Part of the work may therefore involve changing not only the prediction that a sensation is dangerous, but also the relationship with the sensation — gradually moving from fighting the body towards experiencing it with greater curiosity, safety and agency.
Chronic threat and attachment experience
At other times, the relationship between trauma and pain is less direct.
The nervous system may have become highly practised in anticipating danger long before chronic pain developed.
Early attachment experiences can be particularly important because the developing nervous system depends on relationships for regulation and protection.
When safety, proximity or protection were unreliable, the organism may have learned to remain prepared.
In these situations, I am interested in whether pain is occurring within a system that has learned, for very understandable reasons, to protect intensely.
Dissociation, disconnection and pain
Not every response to threat involves becoming more activated. When experience becomes overwhelming, inescapable or impossible to process, the nervous system can also organise around disconnection.
Dissociation can take many forms. A person may feel numb, distant from the body, unreal or somehow absent. Emotions can become difficult to access. Bodily sensations may seem vague or far away, and periods of intense sensation can alternate with periods in which very little is felt at all.
Dissociation may also involve changes in pain perception itself. Under overwhelming or inescapable threat, the nervous system can activate powerful analgesic mechanisms, some of which involve the body's endogenous opioid systems. This may help explain why people can sometimes feel surprisingly little pain during traumatic events, or experience numbness and detachment from the body. In trauma-related dissociation, endogenous opioid mechanisms have been proposed as one contributor to trauma-related analgesia and altered pain perception.
For some people living with chronic pain, this creates a complicated relationship with the body.
There can be moments of intense vigilance towards sensation and other moments of wanting not to feel the body at all.
The person may move between:
too much sensation → overwhelm → disconnection
and
disconnection → reduced contact with the body → sudden return of overwhelming sensation.
Over time, chronic pain and trauma do not necessarily produce one stable nervous-system state. A person may move between hyperarousal — with heightened vigilance and increased sensitivity to pain — and periods of dissociation, numbing or reduced contact with bodily sensation. For me, this oscillation can be clinically as important as the pain intensity itself.
Pain itself can also become sufficiently overwhelming that dissociation becomes a way of getting some distance from what cannot be escaped physically.
When trauma is part of the person's history, these patterns may have developed much earlier. Disconnecting from sensation, emotion or bodily experience may once have been an important way of surviving situations in which neither fighting nor escaping was possible.
This matters when working with chronic pain.
Approaches such as somatic tracking invite a person to attend closely to bodily sensation. For someone whose nervous system relies heavily on dissociation, simply asking them to “feel the body” can sometimes be too much.
The work may therefore need to proceed more gradually — strengthening orientation, presence and the capacity to remain connected while approaching sensation in small enough amounts.
My interest is not in eliminating dissociation as though it were a malfunction.
I am interested in understanding what the disconnection has protected the person from, and whether the nervous system can gradually discover that more contact with the body is possible now without becoming overwhelmed.
Self-directed aggression and suicidal ideation
For some people, prolonged pain can eventually evoke not only fear and the wish to escape, but also anger directed towards the body or towards the self.
When pain is experienced as relentless and inescapable, the person may feel trapped between an urge to fight what is happening and an inability to get away from it.
Anger that cannot find an external direction can sometimes become self-directed, taking the form of self-attack, hatred of the body, self-harming impulses or, in more severe states, suicidal ideation.
From a trauma perspective, I am also interested in what may lie underneath this organisation.
In some people, particularly where there is a history of early attachment trauma, an intense pre-affective shock response may precede experiences of unbearable aloneness, pain, rage, fear or shame.
When defensive action has repeatedly been impossible, some of that mobilisation may eventually become directed towards the self.
This does not mean that suicidal ideation can be reduced to a nervous-system mechanism, or that it always has this origin.
Suicidal thoughts are complex and must always be taken seriously and assessed directly.
But clinically it can be important to distinguish between the wish to die and the desperate wish for an unbearable state — pain, entrapment, internal attack or emotional suffering — to end.
The question then becomes not only:
Where does it hurt?
but also:
What is the nervous system preparing for?
What danger is it expecting?
And does it still need to protect in the same way now?
And does it still need to protect in the same way now?
Shock can be especially important
Shock happens extremely quickly.
Before we have consciously organised an experience into fear, anger, grief or narrative, the nervous system has already oriented towards what is happening and registered its impact.
In some overwhelming states, shock may also be accompanied by analgesia, numbing or dissociative detachment. Endogenous opioid-mediated mechanisms are one possible contributor to this reduction in pain perception. This means that the immediate response to an injury or traumatic event may sometimes involve surprisingly little pain, followed later by a very different pattern of bodily sensitivity.
After an accident, injury, surgery, frightening medical procedure or other overwhelming experience, a person may consciously know:
It is over.
Yet some part of the nervous system may continue to behave as though danger is still imminent.
The body may have braced.
It may have prepared to fight or escape.
There may have been an impulse to turn away, push something away, protect a vulnerable part of the body or get out of danger.
There may also have been sudden disorientation, helplessness or the shock of impact itself.
When chronic pain began around such an experience, I am interested not only in the painful sensation but also in what happened in the nervous system around the moment in which pain and danger became linked.
Deep Brain Reorienting and chronic pain
My interest in chronic pain is strongly influenced by my work with trauma and Deep Brain Reorienting.
I am an approved Deep Brain Reorienting practitioner and have been integrating DBR into my psychological practice for more than three years, alongside ongoing consultation, professional development and assisting at DBR trainings.
DBR was developed primarily as a trauma-focused approach rather than specifically as a chronic-pain treatment.
I use it in chronic pain work when trauma or shock appears to be an important part of the person's experience.
DBR pays particular attention to the sequence:
orienting → shock → emotional and defensive response.
Instead of immediately moving into fear, grief, anger or the story of what happened, we slow the process down and attend to the earlier physiological responses associated with orienting and shock.
This can be particularly relevant when pain began during an experience that the nervous system registered as overwhelming:
orienting / threat → shock → mobilisation or analgesic-dissociative response → later pain and defensive organisation.
I do not understand this as trauma being literally “stored” in the painful body part.
I think of it more as a nervous system that may still be organising present experience around an earlier prediction of danger.
When this is part of the pain picture, working with shock can complement the process of changing the brain's interpretation of bodily sensations.
PRT and DBR: different entry points
Pain Reprocessing Therapy and DBR approach the nervous system from somewhat different directions.
PRT asks:
Is the nervous system interpreting a safe bodily signal as dangerous?
DBR asks:
What happened when threat was first registered — before the fully developed emotional response?
PRT asks:
Is the nervous system interpreting a safe bodily signal as dangerous?
DBR asks:
What happened when threat was first registered — before the fully developed emotional response?
I find these perspectives complementary.
Sometimes chronic pain work focuses mainly on changing fear of bodily sensation and movement.
Sometimes the pain is closely connected with a traumatic event, and the shock surrounding that experience also needs attention.
Sometimes attachment, dissociation, anger, chronic stress or relational experience are significant parts of the picture.
And sometimes they are not.
I do not apply one explanation to everybody.
I am interested in understanding what is maintaining this person's pain.
Rebuilding trust in the body
One of the consequences of chronic pain can be a profound loss of trust in the body.
The body may begin to feel fragile.
Unpredictable.
Dangerous.
People can gradually organise their lives around preventing symptoms.
Movement becomes restricted.
Attention becomes increasingly focused on detecting pain.
The possibility of another flare may become threatening before anything has actually happened.
Part of the work is often helping the body become inhabitable again.
That may involve rediscovering movements that feel safe, attending to sensations without immediately preparing for catastrophe, noticing experiences of strength, pleasure or neutrality as well as pain, and allowing the nervous system to accumulate experiences that contradict its expectation of danger.
The aim is not to fight the body.
It is to help the nervous system discover that it may no longer need to protect quite so intensely.
Unpredictable.
Dangerous.
People can gradually organise their lives around preventing symptoms.
Movement becomes restricted.
Attention becomes increasingly focused on detecting pain.
The possibility of another flare may become threatening before anything has actually happened.
Part of the work is often helping the body become inhabitable again.
That may involve rediscovering movements that feel safe, attending to sensations without immediately preparing for catastrophe, noticing experiences of strength, pleasure or neutrality as well as pain, and allowing the nervous system to accumulate experiences that contradict its expectation of danger.
The aim is not to fight the body.
It is to help the nervous system discover that it may no longer need to protect quite so intensely.
Chronic pain also exists in a social world
My background in the social sciences influences how I understand pain.
A nervous system does not exist separately from the person's life.
Pain is experienced within relationships, families, cultures, work environments, medical systems and wider social conditions.
Financial pressure, caregiving, migration, isolation, disability, gender expectations, difficult working conditions or uncertainty about the future can all affect the conditions in which a nervous system is trying to regulate itself.
Being repeatedly disbelieved about pain can itself be deeply distressing.
So can receiving frightening or contradictory explanations from professionals.
I therefore do not reduce chronic pain to a problem of “nervous-system regulation.”
Sometimes the nervous system is responding to real conditions of threat or strain in the person's life.
Those conditions also deserve to be understood.
Is my pain neuroplastic?
Determining whether pain has a neuroplastic or nociplastic component means looking at the whole pattern rather than one symptom.
I become particularly interested in a neuroplastic contribution when:
- symptoms fluctuate considerably;
- pain changes location or spreads;
- stress and emotional states strongly influence symptoms;
- symptoms appear in the absence of corresponding structural change;
- medically safe activities reliably provoke pain;
- pain began during a period of significant threat, stress or trauma;
- symptoms persist despite adequate tissue healing;
- there is strong fear or vigilance around particular sensations or movements;
- or several pain and sensory symptoms coexist.
The more these patterns occur together — particularly when medical findings do not adequately explain the severity or behaviour of the symptoms — the more relevant neuroplastic mechanisms may become.
Medical assessment still matters
New, changing or unexplained pain requires appropriate medical assessment.
Nociceptive pain related to tissue injury, neuropathic pain related to nerve damage and nociplastic pain related to altered nociception can coexist in the same person.
Someone can have a genuine structural condition and a nervous system that has become increasingly protective around it.
The useful question is therefore not:
Is this physical or psychological?
but:
What processes are contributing to this person's pain now?
My experience with chronic pain work
I have completed foundational training in Pain Reprocessing Therapy (PRT), am currently undertaking Advanced Training, and am listed in the Pain Reprocessing Therapy Institute's Mental Health Clinician Directory.
I am also an approved Deep Brain Reorienting practitioner.
My particular interest is in the meeting point between chronic pain, neuroplasticity, threat, shock, trauma and embodied experience.
My background in psychology and the social sciences, alongside extensive training in body psychotherapy and trauma-focused somatic approaches, means that I do not understand pain as either purely physical or purely psychological.
I am interested in the whole system through which pain is being experienced: brain, body, history, relationships and social world.
Online work with chronic pain
Online work can be particularly useful when pain, fatigue or mobility make travelling difficult.
Sessions require a private and stable environment where we can maintain reliable visual and verbal contact.
Her professional background combines psychology and the social sciences with extensive training in body psychotherapy, Pain Reprocessing Therapy, Deep Brain Reorienting and other contemporary trauma-focused approaches.
She is an approved DBR practitioner and is currently undertaking Advanced Training in Pain Reprocessing Therapy.
Based in Switzerland, she works online with international clients where professionally permitted. Sessions are available in English, Italian and Russian.
You are welcome to contact me for an initial conversation.
We can look together at the pattern of your pain, what you have already tried, what is known medically about your symptoms, whether there are signs of a neuroplastic component, and whether pain reprocessing, trauma-focused work or a broader somatic approach may be useful.
We can look together at the pattern of your pain, what you have already tried, what is known medically about your symptoms, whether there are signs of a neuroplastic component, and whether pain reprocessing, trauma-focused work or a broader somatic approach may be useful.