Behavioural and neural evidence for self-reinforcing expectancy effects on pain
Open accessAbstract
Beliefs and expectations often persist despite evidence to the contrary. Here we examine two potential mechanisms underlying such 'self-reinforcing' expectancy effects in the pain domain: modulation of perception and biased learning. In two experiments, cues previously associated with symbolic representations of high or low temperatures preceded painful heat. We examined trial-to-trial dynamics in participants' expected pain, reported pain and brain activity. Subjective and neural pain responses assimilated towards cue-based expectations, and pain responses in turn predicted subsequent expectations, creating a positive dynamic feedback loop. Furthermore, we found evidence for a confirmation bias in learning: higher- and lower-than-expected pain triggered greater expectation updating for high- and low-pain cues, respectively. Individual differences in this bias were reflected in the updating of pain-anticipatory brain activity. Computational modelling provided converging evidence that expectations influence both perception and learning. Together, perceptual assimilation and biased learning promote self-reinforcing expectations, helping to explain why beliefs can be resistant to change.
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Early evidence indicates biases in pain perception caused by predictive cues can short-circuit learning, creating positive feedback loops between predictions and experiences that result in resistance to disconfirming evidence.
“Studies of confirmation bias in direct perceptual experiences like pain are more rare, but early evidence indicates biases in pain perception caused by predictive cues can short-circuit learning, creating positive feedback loops between predictions and experiences that result in resistance to disconfirming evidence (26).”
From Social information creates self-fulfilling prophecies in judgments of pain, vicarious pain, and cognitive effort (2026) · cites this paper as [26]
Even cues conditioned to conceptual representations of reinforcers can elicit enduring effects in some cases.
“Even cues conditioned to conceptual representations of reinforcers (e.g., images of thermometers indicating high or low pain) can elicit enduring effects in some cases (26).”
From Social information creates self-fulfilling prophecies in judgments of pain, vicarious pain, and cognitive effort (2026) · cites this paper as [26]
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Wolf, M., Wittkamp, C. A., & Rose, M. (2024) · Scientific Reports · doi:10.1038/s41598-024-77693-z · Cited by 4 · see citing works
Bayesian surprise intensifies pain in a novel visual-noxious association
Ishikawa, R., Ono, G., & Izawa, J. (2025) · Cognition · doi:10.1016/j.cognition.2025.106064 · Cited by 4 · see citing works
Neurophysiological encoding of aversive prediction errors
Gopalakrishnan, R., Sonneborn, C., Baillet, S., Machado, A. G., Wager, T. D., & Roy, M. (2025) · Pain · doi:10.1097/j.pain.0000000000003712 · Cited by 4 · see citing works
Self-citationExposure to false cardiac feedback alters pain perception and anticipatory cardiac frequency
Parrotta, E., Bach, P., Pezzulo, G., Zaccaro, A., Perrucci, M. G., Costantini, M., & Ferri, F. (2026) · eLife · doi:10.7554/elife.90013.3 · Cited by 3 · see citing works
Learning the statistics of pain: computational and neural mechanismsPreprint
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Expectation generation and its effect on subsequent pain and visual perception
Botvinik‐Nezer, R., Geuter, S., Lindquist, M. A., & Wager, T. D. (2025) · PLoS Computational Biology · doi:10.1371/journal.pcbi.1013053 · Cited by 3 · see citing works
Self-citationRethinking coping in chronic pain: a systematic review and dynamic interaction model of coping
Blandhol, M., Lee, S. Y., & Ellingsen, D. (2026) · PAIN Reports · doi:10.1097/pr9.0000000000001421 · Cited by 3 · see citing works
Brain rhythms of depression: A predictive processing perspective
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Predictability of placebo responses and their clinical implications
Branco, P., Vachon‐Presseau, É., Hall, K. T., Wager, T. D., & Apkarian, A. V. (2023) · Oxford University Press eBooks · doi:10.1093/med/9780197645444.003.0005 · Cited by 3 · see citing works
Self-citationNeural mechanisms underlying placebo and nocebo effects in tonic muscle pain
Chen, M., Wu, X. X., Zhang, L., Zhang, F., Li, L., Zhang, Y., Xiong, D., Qiu, Y., Hu, L., & Xiao, W. (2024) · NeuroImage · doi:10.1016/j.neuroimage.2024.120877 · Cited by 3 · see citing works
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Reproducible, Generalizable Brain Models of Affective Processes
Kragel, P. A., & Wager, T. D. (2019) · Nebraska Symposium on Motivation/The Nebraska symposium on motivation · doi:10.1007/978-3-030-27473-3_8 · Cited by 2 · see citing works
Self-citation
- Authors
- Jepma, M., Koban, L., van Doorn, J., Jones, M., & Wager, T. D.
- Affiliations
- Leiden University (NL)
- University of Colorado Boulder (US)
- Dartmouth College (US)
- Corresponding author
- Jepma, Marieke
- Venue
- Nature Human Behaviour
- Published
- 2018-10-29
- Volume
- 2
- Issue
- 11
- Pages
- 838-855
- ISSN
- 2397-3374 (ISSN-L)
- PMC
- PMC6768437
- OpenAlex
- W2898173573
- Cited by
- 155
- References
- 130
- Citations by year
- 2026: 19 · 2025: 21 · 2024: 29 · 2023: 25 · 2022: 19 · 2021: 20 · 2020: 11 · 2019: 10 · 2018: 1
- FWCI
- 6.25
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Licence
- Locations
- Nature Human Behaviour (publishedVersion)
- PubMed (publishedVersion)
- UvA-DARE (University of Amsterdam) (publishedVersion)
- PubMed Central (acceptedVersion)
- HAL (submittedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- OSF Preprints (OSF Preprints) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Funders
- National Institute of Mental Health (R01MH076136)
- National Institute on Drug Abuse (R01DA027794)
- Topics
- Life Sciences › Neuroscience › Cognitive Neuroscience › Pain Management and Placebo Effect
- Health Sciences › Medicine › Physiology › Pain Mechanisms and Treatments
- Life Sciences › Neuroscience › Cognitive Neuroscience › Neural and Behavioral Psychology Studies
- Keywords
- pain anticipation, confirmation bias, biased learning, pain perception, expectation updating, belief updating, thermal pain, computational modelling, individual differences
- MeSH terms
- Adult, Brain, Brain Mapping, Culture, Female, Humans, Learning, Male, Motivation, Neuropsychological Tests, Pain, Psychological Theory, Reinforcement, Psychology, Pain Perception
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
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