Why harmless sensations might hurt in individuals with chronic pain: about heightened prediction and perception of pain in the mind
Open accessAbstract
In individuals with chronic pain harmless bodily sensations can elicit anticipatory fear of pain resulting in maladaptive responses such as taking pain medication. Here, we aim to broaden the perspective taking into account recent evidence that suggests that interoceptive perception is largely a construction of beliefs, which are based on past experience and that are kept in check by the actual state of the body. Taking a Bayesian perspective, we propose that individuals with chronic pain display a heightened prediction of pain (prior probability p(pain)), which results in heightened pain perception (posterior probability p(pain|sensation)) due to an assumed link between pain and a harmless bodily sensation (p(sensation│pain)). This pain perception emerges because their mind infers pain as the most likely cause for the sensation. When confronted with a mismatch between predicted pain and a (harmless bodily) sensation, individuals with chronic pain try to minimize the mismatch most likely by active inference of pain or by an attentional shift. The active inference results in activities that produce a stronger sensation that will match with the prediction, allowing subsequent perceptual inference of pain. Here, we depict heightened pain perception in individuals with chronic pain by reformulating and extending the assumptions of the interoceptive predictive coding model from a Bayesian perspective. The review concludes with a research agenda and clinical considerations.
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Precision on unfulfilled prior preferences can be a persistent source of suffering to the system-one such example being chronic pain, where chronic pain is underpinned by high precision on a prior preference that is unable to be fulfilled through action.
“Precision on unfulfilled prior preferences can be a persistent source of suffering to the system—one such example being chronic pain, where chronic pain is underpinned by high precision on a prior preference that is unable to be fulfilled through action (Hechler et al. 2016).”
From Consciousness in active inference: Deep self-models, other minds, and the challenge of psychedelic-induced ego-dissolution (2021) · cites this paper as Hechler et al. 2016
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Karoly, P. (2021) · Comprehensive Clinical Psychology · doi:10.1016/b978-0-12-818697-8.00117-5 · Cited by 2 · see citing works
Acute Amnesia Resulting in Complete Relief of Pain, Depression, and Anxiety
Ohmura, J. F., Sussman, C. B., Zamani, A. A., Nedeljković, S. S., & Lyndon, S. (2025) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2025.06.015 · Cited by 1 · see citing works
Fear-learning is altered in a mouse neuropathic pain model
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Reimagining pain as an allostatic imperative: perspectives from contemplative traditions
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Brand, S., Lang, K., & Jungmann, S. M. (2025) · Kindheit und Entwicklung · doi:10.1026/0942-5403/a000491 · Cited by 1 · see citing works
Il corpo: dalla costruzione delle emozioni al dolore
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A Bayesian Model for Chronic PainPreprint
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Prehabilitation and Rehabilitation as Pathways to Improved Perioperative Analgesia
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Das Gehirn ist heute die Psyche von gestern
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Classic Psychedelics for Treating Chronic Pain: Mechanism and Clinical Translation
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- Authors
- Hechler, T., Endres, D., & Thorwart, A.
- Affiliations
- Universität Trier (DE)
- Philipps University of Marburg (DE)
- Corresponding author
- Hechler, Tanja
- Venue
- Frontiers in Psychology
- Publisher
- Frontiers Media SA
- Published
- 2016-10-25
- Volume
- 7
- Pages
- 1638-1638
- ISSN
- 1664-1078 (ISSN-L)
- PMC
- PMC5078757
- OpenAlex
- W2537237778
- Cited by
- 76
- References
- 46
- Citations by year
- 2026: 5 · 2025: 10 · 2024: 7 · 2023: 9 · 2022: 13 · 2021: 10 · 2020: 8 · 2019: 4 · 2018: 4 · 2017: 6
- FWCI
- 2.97
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- Frontiers in Psychology (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Life Sciences › Neuroscience › Cognitive Neuroscience › Embodied and Extended Cognition
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Health Sciences › Medicine › Physiology › Pain Mechanisms and Treatments
- Keywords
- chronic pain, interoception, pain perception, active inference, attentional shift, pain prediction, perceptual inference
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.
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