For someone living with chronic pain, being told, “It’s all in your head,” can feel incredibly dismissive. It can sound as though the pain isn’t real or that it should be ignored.

Fortunately, modern pain science tells us something very different. Pain is always real, but it isn’t a direct measure of tissue damage. Instead, the brain creates pain based on many sources of information, including what’s happening in the body, past experiences, emotions, and expectations. In other words, the amount of pain you experience isn’t always proportional to the amount of injury in your body. Especially with chronic pain, the brain can become highly protective, producing pain even after tissues have healed.

Researchers call this the nocebo effect—the opposite of the placebo effect. Just as positive expectations can reduce pain, negative expectations can amplify it. This doesn’t mean the pain is imagined; it means the brain and nervous system are responding to a perceived threat.

Two Remarkable Stories

Two well-known case reports illustrate just how powerfully expectations can shape pain.

The first comes from a 1995 article published in the British Medical Journal (BMJ). A 29-year-old construction worker jumped onto a 6-inch nail. He was in excruciating pain, so much so that he required sedation before the nail could be removed. When his boot was finally cut off, everyone was shocked. The nail had passed cleanly between his toes without causing any injury to his foot. His pain was completely real—but the injury his brain believed had occurred never actually happened.

Now consider another construction worker:

In 2005, a 23-year-old man visited his dentist complaining of a persistent toothache. During the examination, imaging revealed a four-inch nail embedded in his skull, barely missing his eye.

Six days earlier, while using a nail gun, he believed the tool had simply kicked back and struck him in the face. Unaware that a nail had entered through his mouth and into his skull, he treated what he assumed was a minor injury with ice and over-the-counter pain medication for nearly a week.

At first glance, these stories seem contradictory. One man experiences excruciating pain from an injury that never actually occurred, while another lives for six days with a nail embedded in his skull and experiences only a mild headache. Together, they illustrate an important principle: our experience of pain is shaped not only by what is happening in the body, but also by what the brain believes is happening.

As Dr. Loren Martin, a researcher at the University of Toronto, explains:

“Nocebo-related pain is not simply imagined or exaggerated. The brain is actively generating a real biological pain response through a specific neural circuitry.”

Why This Matters for Chronic Pain

Understanding the nocebo effect can be incredibly empowering for people living with chronic pain. It helps explain how a nervous system can become highly sensitive—not because someone is “making it up,” but because the brain has learned to become extra protective.

Imagine a smoke alarm that goes off every time you make toast. The alarm is functioning exactly as designed—it is just too sensitive. Chronic pain can work in a similar way. The nervous system begins sounding the alarm even when the body is no longer in danger. The goal isn’t to ignore the alarm, but to help recalibrate it.

This idea is central to several evidence-based approaches to chronic pain, including Pain Reprocessing Therapy (PRT). PRT focuses on helping people understand how the brain and nervous system contribute to chronic pain and teaches skills that can reduce fear, increase a sense of safety, and gradually retrain the brain’s response to pain.  For many people, learning how the brain and body work together can be an important step toward reducing suffering and reconnecting with the activities and relationships that matter most.

If you’re living with chronic pain and are curious about whether these approaches might be helpful, I’d be happy to explore them with you and discuss whether they’re a good fit for your goals. Don’t hesitate to reach out and get started today!