Why Harmless Sensations Might Hurt in Individuals with Chronic Pain: About Heightened Prediction and Perception of Pain in the Mind

Abstract

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 alternatively by an attentional shift away from the sensation. 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.

Exposing Pathological Sensory Predictions in Tinnitus Using Auditory Intensity Deviant Evoked Responses

“…Predictive coding accounts of perception (Rao and Ballard, 1999;Friston and Kiebel, 2009) are popular in neuroscience, and our predictive coding tinnitus model (Sedley et al, 2016) joins other predictive coding models of tinnitus (De Ridder et al, 2014a;Durai et al, 2018), and other pathological perceptual states, including chronic pain (De Ridder et al, 2014a;Hechler et al, 2016;Geuter et al, 2017;Nir and Yarnitsky, 2015), musical hallucinosis (Kumar et al, 2014), psychosis (Adams et al, 2013), and functional neurological disorder (Edwards et al, 2012). These theoretical models generally lack support by measurement of the pathological predictions themselves.…”

Tired of pain? Toward a better understanding of fatigue in chronic pain

“…Established pain theories on fear-avoidance [58] and catastrophic thinking [45], argue that chronic pain patients appraise pain in an excessively negative way, resulting in heightened pain expectancies. Recently, models of predictive coding and inferential decision-making have been applied to understand why chronic pain patients have heightened pain expectations and how this might shape actual pain perceptions and guide action [24,40,63]. We hypothesize these processes to increase the weight of the costs associated with the behaviour, and thus to induce fatigue.…”

Symptoms and the body: Taking the inferential leap

“…These assumptions have recently been elaborated for interoceptive and affective information processing and their interaction with external perception (Barrett and Bar, 2009;Edwards et al, 2012;Seth, 2013;Barrett and Simmons, 2015). Chronic pain has recently been conceptualized using a predictive coding perspective, as has the modulation of pain perception by placebo and nocebo expectations (see Büchel et al, 2014;Hechler et al, 2016;Wiech, 2016). Our account builds on these approaches.…”