Chronic Pain & Pain-Brain-Maps

What is Pain?

Fundamentally, pain is a threat signal, and it is only experienced as pain once our brain converts the signal into the experience of pain. Think of accidentally placing your hand on a hot pan. The nerves in your hand register the heat, send that information to the brain which recognizes that the level of heat is dangerous (ie:/ threatening), which converts the “experience of your hand” into one of pain, making you reflexively jerk your hand away and back to safety. 

This mechanism, which converts the neutral information from our sensory nerves into an experience of pain, is a major component of how anesthetics work. Namely, they turn off the part of the brain which converts the information into pain. 

As with anything, fundamentally understanding what something is gives us greater agency to work with it. Applying this concept to pain may seem silly or unnecessary. After all, a baby knows what pain is, and it knows to cry in response to it. That doesn’t give us any agency though, which is something people who suffer from Chronic Pain Syndrome experience. 

Pain-Brain-Maps

So, how does this work? Our brain has a “map” of our body corresponding to our sensory nerves. It is very important to note that this map is not a one-to-one correlation between our actual body parts and our experience of them. The best example to illustrate this is Phantom Limb Syndrome, especially when someone experiences pain in their phantom limb. This is when someone physically loses a limb, but still sensorially/experientially has it, and can still experience pain in the limb that they no longer have (it is important to note that non painful sensations can also be experienced). 

Chronic Pain

Chronic pain is an experience of pain not necessarily stemming from a physical stimulus. In other words, it is essentially psycho-somatic. This does not mean it isn’t real. It just means it isn’t physically derived pain, in the sense that we understand that (like touching a burning hot pan and feeling pain). It is neurologically (and to a large degree psychologically) derived. This can also be true for pain that has a physical stimulus, but the level of pain is amplified out of proportion.

When someone develops Chronic Pain Syndrome (the pathological extremis of chronic pain), the Pain-Brain-Map has become chronically misrepresentative, or de-correlated to the physical reality.

When someone who does not have Chronic Pain Syndrome experiences pain, say, in their right thumb, the neurological area in their Pain-Brain-Map will “light up” - meaning the neurons activate - up to about 5% of the surface area. When someone with Chronic Pain Syndrome experiences pain in their right thumb, the neurological area in their Pain-Brain-Map will “light up” to about 25%. In other words, the person with Chronic Pain Syndrome will experience their thumb as 5x as large as the person without Chronic Pain Syndrome, and therefore will be experiencing significantly more pain. This also makes the experience of pain radiate, as the map which used to portray just the thumb will now cover parts of the hand, wrist, and so on.

What To Do About All of This: Two Phases

Phase One: Nervous System Regulation

The first step is to get the overall nervous system to calm down (ie/ less fight/flight). 

Let’s go back to the hand-touching-a-hot-pan example. The pain in your hand is fundamentally a threat signal, so when you jerk your hand back, you’re also on high alert: heart pumping, sharp breaths, muscles and tendons poised to react. That’s a fight/flight state (Sympathetic Dominance). Once you determine that the threat (pain) is from the hot pan, and is functionally neutralized, you can calm back down and get out of a fight/flight state. 

If you are chronically experiencing pain, however, your system is chronically sending and being bombarded with threat signals, and is, therefore, always in some level of a fight/flight state. Due to the nature of a fight/flight state, which says “we are in danger, our primary consideration needs to be dealing with that threat,” it does not leave a lot of room for normal functioning. But it does leaves a lot of room for the threat, or at least the focus on the threat, to grow larger. This exactly parallels anxiety, where some threat, however vague, is detected, and normal functioning becomes harder as all resources are directed towards dealing with that threat. 

In other places, I write and speak extensively on how to work on regulating your nervous system out of a Sympathetic Dominant state. In short, it includes, but is not limited to, Heart Rate Variability (HRV) Biofeedback, other types of Biofeedback, Neurofeedback, Vagus Nerve Regulation, Ketamine Assisted Psychotherapy, Cold Plunges, and Meditation/Mindfulness. If you have a trauma background, that needs to be worked through psychotherapeutically, as it is informing your nervous system to constantly be alert. 

In short, it’s about gaining functional agency over your nervous system, and training it to a new default of balance, calm, and safety.

Phase Two: Experience Something Besides Pain

Accomplishing Phase One gives you a greater level of nervous system regulation, as well as the ability to regulate yourself in real time. Now we can move onto the next phase, which directly targets the Pain-Brain-Maps. 

As pain becomes chronic and the Pain-Brain-Map increases, the brain is essentially preemptively experiencing pain, with or without a physical stimulus. What we need to do, then, is introduce another experience which is not painful, as a competing response against the expected pain. This can eventually shrink the Pain-Brain-Map back to an appropriate size (or at least to a smaller size), and eliminate or reduce the expectation, and subsequent creation, of pain. 

What This Looks Like In Practice

I’ll bring in examples of two different clients I worked with on Chronic Pain using this understanding. The first client I’ll call Kim, which is not her real name. 

Kim: Phase One (Nervous System Regulation)

Kim had been experiencing chronic pain around her eye sockets for approximately 18 months before I began working with her. This had begun shortly after some major dental work, and it’s possible that it was a type of nerve damage called Trigeminal Neuralgia, though the diagnosis was not confirmed. 

We began with HRV Biofeedback, to regulate her Autonomic Nervous System. Then we did approximately eight sessions of Alpha/Theta Neurofeedback in the Parietal region of her brain. Then we did a Vagus Nerve Regulation training using audio-waves. 

Throughout all of this we were working to build a more conscious engagement with her interoceptive process, which is a somewhat more technical version of “mindfulness.” Essentially, this involved becoming consciously aware of the sensational experience in her body, as well as in her mind, as her nervous systems achieved greater levels of regulation. 

Kim: Phase Two (Experience Something Besides Pain)

Once that groundwork was laid, and she had a qualitatively different experience and relationship to herself, we began with Phase Two. I instructed Kim to close her eyes, and focus on her right palm. With her other hand, I asked her to gently trace her palm and fingers, slowly and repetitively. She described the sensation as somewhere between ticklish and pleasurable. We worked on using this sensation as an anchor for her mind as it inevitably drifted, and to become as aware of the sensation as possible. Because she had diligently engaged in Phase One, regulating her nervous system, she was already well practiced in this type of sensationally based mindfulness. 

The purpose of this hand tracing exercise was to prime her system, including the brain map, to be attenuated to non-painful sensation. We began in her palm as it was a neutral location, far from her eye sockets. After enough time had passed for her to have somewhat meditatively sunken into the sensational experience in her palm, I asked her to take the same finger she had been using to trace her palm and trace it around her right eye socket in the same gentle manner. I deliberately instructed her to not engage with her left eye socket. 

At first, there was some trepidation, as such a strong association had developed between that physical location and the expectation/sensation of pain. However, because she had primed her sensory system by engaging in the neutral location of her palm with the pleasurable sensations, and had done the upfront work of retraining her nervous system to a less reactive, more balanced state, she was able to tolerate the initial trepidation and expectation of pain, and tap into the actual experience of the gentle tickle of her finger tracing her eye socket. Just like with her palm, she continued for a number of minutes and meditatively sunk into the sensation. 

After approximately 10 minutes, she stopped, and said that her right eye socket did not have any pain, just the faint memory of the ticklish sensation. Her left eye socket, on the other hand, she described as having “received” the pain from the right side and was experiencing double pain. 

I mindfully guided her to tap into the sensation of both eye sockets. My goal at that point was to help her realize that she actually has a significant level of agency over her experience of pain. After all, she just caused it to migrate from one side to the other! 

We then moved on to the left eye socket in a similar fashion, and kept playing with her agency over her sensational experience. 

John: Phase One (Nervous System Regulation)

John was a 74 year old man who had experienced chronic back pain for about 20 years, and was scheduled for a third back surgery in 4 months when we began working together. He reached out as he knew, on some level, that his experience of pain was not just physical, but that there was a strong psychological element as well. 

My work with John was fully remote, so we were unable to do the Alpha/Theta Neurofeedback that I had done with Kim. We were able to do the HRV Biofeedback as well as the Vagus Nerve Regulation Training. We also worked more closely on self regulation on a day-to-day basis, resembling Peak Performance Training more than psychotherapy. This included noticing points in his day where his stress levels felt unreasonably high, and working on self regulation in those moments to achieve the desired task. The task of reading became a very clear barometer, as he could not focus when dysregulated, and it became a good indicator of when to practice some of the tools, either physiological or mental. 

As is true with the proverbial bicycle tire, it does not matter what spoke you start with; they all lead to the hub. Learning to self regulate in this fashion gave John agency within his nervous system, and resulted in a new default state that was more balanced. As part of this, he came to know himself in a different way, and learned how to respond to triggers from a place of curiosity or observation, rather than being consumed by his stress reaction, whether it resembled anxiety, fear, anger, or confusion. 

John: Phase Two (Experience Something Besides Pain)

Part of John’s experience included pain in the shins and calves. As with Kim, we began with gentle palm tracing. Once sufficiently primed and attenuated, we moved onto an area of his leg which was painful at that moment, and traced a similar pattern there. 

After a few moments, John said “motherfu**er, it doesn’t hurt as much anymore.”  

I laughed, happy it was working, hopeful he could really change this aspect of his life. Then I stopped laughing. John was genuinely angry. 

A CAVEAT: THE IDENTITY OF PAIN

John’s anger at first surprised and confused me. His pain was lessening, and he was in charge of that. Isn’t that a good thing? I then realized that there was more to his pain than just an inflamed Pain-Brain-Map. There was an identity to the pain, a relationship. In other words, it wasn’t just neurological, it was psychological as well. 

The modality of Internal Family Systems, which understands that our psyche has distinct “parts” or “voices,” most simply explains my perspective in the following interaction. I asked John to “let the anger speak.” It said: 

“You son of a bit*h, you’re telling me that we’ve been debilitated by this sh*t for 20 fuc*ing years and all I had to do was trace some fuc*ing circles on my skin!? You as*hole, I don’t know what psychological voodoo sh*t you’re playing at, or why I’m susceptible to it right now, but I’m sure this’ll all fade away as soon as I stop.” 

“It sounds like you’re quite mad at me, and maybe at John as well,” I said.

“You’re damn right I am. You and him and that garbage physical therapist who told me I’m gonna feel so much better after my surgery. How the hell can she say that to me? This is my 3rd surgery. What if I don’t?”

“It sounds like you’re trying to protect John against false hopes,” I said. 

“False hopes. More like false prophets and lying fuc*ing professionals who are supposed to be helping me.” 

“Is the fear that if John gets his hopes up, and they are not met, the fall will be crushing?”

“Not ‘if’ they’re not met. When they’re not met.”

“I see. It sounds like you’re speaking from experience,” I said.

“Yeah, we’ve been through this before. Same BS every time.”

“I understand that. And those sound like sh*tty experiences. And I agree with you, I don’t think it was right of that PT to say something like that to you.” 

“Yeah, well, you’re doing the same thing.” 

“I could be, I’m open to being wrong here. And if I am, I’d be eager for you to point out how, more specifically.” John/his anger didn’t say anything for a beat. “Can I ask you a question?” I said.

“What?”

“Can you tap in, right now, to the experience of your leg at the spot you were tracing? John, I’m speaking to you as well as your anger.” I could see that he was doing it. “Your experience is one of less pain, at least compared to 15 minutes ago. Isn’t it?” 

“Yes, it is,” John said, and his tone was different. Milder. 

“Does the angry part recognize that too?” I asked.

“That angry voice recognizes that too.” 

“John, that angry voice is just trying to protect you, to help you, in the best way it knows how. Your work now is to engage with it, acknowledge its efforts and intentions, and also help it understand that you are in charge, and you need its input, but you ultimately make the decision. You need to help that angry part experience reality, and allow you to experience reality, rather than just protect you from a potential worst case scenario. Right now, reality is that your leg hurts less than it did 15 minutes ago.”

The work after this point was twofold, in the same integrative way that’s displayed above. John continued introducing a non-pain signal into his Pain-Brain-Map, and whenever that “part” would come up, he needed to work with it. In essence, he needed to do the internal work to stop identifying as someone with chronic pain. This is a scary process, and one that is naturally resisted. But that’s what’s needed. John courageously and diligently practiced. His pain has not completely gone away - he has a very injured back, after all - but his experience of pain, his relationship to it, has fundamentally changed. This led, both through our work but more so in his personal life, to a different relationship with himself, to others, and to the experience of life itself. 

And with Kim, we were unable to accomplish that. The experience of having agency over her pain was so radically different from the self-protective “identity” associated with experiencing chronic pain, that it was experienced essentially as a threat (think: ego-death), which she briefly, obscurely alluded to in the final minutes of the session described above. Unfortunately, we were unable to address it at that moment, and she cancelled her following sessions. 

In Short

Chronic pain is not just a sensory event—it is a lived relationship between the nervous system, the brain’s body-maps, and the parts of ourselves that have learned to anticipate threat. As the cases of Kim and John illustrate, the experience of pain can expand, migrate, or even loosen its grip depending on how the nervous system is regulated and how we relate to the sensations themselves. When we build the capacity to shift out of a chronic threat-detection state, we create enough internal space for something new to occur: the possibility of experiencing the body without fear, without hypervigilance, and without the inevitability of pain.

This work is not quick, nor is it easy. It asks people to retrain long-entrenched neural pathways and, equally important, to renegotiate the psychological identities built around pain and suffering. But it is possible. And when it works—when someone begins to feel even a small pocket of agency inside an experience that once felt totalizing—the path toward physical and psychological freedom becomes real. Chronic pain does not have to define a life. With the right tools, attunement, and support, it can become something understood, worked with, and ultimately reshaped.