How expectations shape pain

Pain is highly modifiable by psychological factors, including expectations. However, pain is a complex phenomenon, and expectations may work by influencing any number of processes that underlie the construction of pain. Neuroimaging has begun to provide a window into these brain processes, and how expectations influence them. In this article, we review findings regarding expectancy effects on brain markers of nociception and how expectations lead to changes in subjective pain. We address both expectations about treatments (placebo analgesia and nocebo effects) and expectations about the environment (e.g. expectations about pain itself). The body of work reviewed indicates that expectancies shape pain-intensity processing in the central nervous system, with strong effects on nociceptive portions of insula, cingulate and thalamus. Expectancy effects on subjective experience are driven by responses in these regions as well as regions less reliably activated by changes in noxious input, including the dorsolateral prefrontal cortex and the orbitofrontal cortex. Thus, multiple systems are likely to interact and mediate the pain-modulatory effects of expectancies. Finally, we address open questions regarding the psychological processes likely to play an intervening role in expectancy effects on pain.

► Expectations about stimuli and expectations about treatments influence pain.
► Expectancies affect pain intensity processing in insula, cingulate, and thalamus.
► Pain-related regions and prefrontal circuits predict expectancy effects on pain reports.
► Intervening processes such as attention, affect, and control need further study.
► Likely to be important differences between expectations about stimuli and expectations about treatments.