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Expecting pain

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Abstract

There is a large amount of evidence of placebo and nocebo effects showing that one’s expectation of a forthcoming pain can influence the subsequent experience of pain. Here I shall not discuss the implications of these findings for the nature of pain, but focus instead on the nature of pain anticipation itself. This notion indeed remains poorly analysed and it is unclear what type of anticipatory state it involves. I shall argue that there is more to pain anticipation than a mere combination of anticipatory beliefs and fears. When the impending damage is imminent, pain anticipation involves a distinctive sui generis mental state, which I call nociceptive prediction. One then anticipates the forthcoming event under the pain mode. After analysing its points of similarities and differences with pain, I shall argue that nociceptive prediction is best understood in imperative defensive terms.

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Notes

  1. There is a wide variety of pains and one may wonder whether it is the same to expect the pain of a vaccine injection, the pain of a heavy handbook falling on your foot, and the monthly pain of your menstruation cramps. Here I leave aside the anticipation of certain types of pain, such as visceral pains, and focus only on the pain caused by external threats and in principle avoidable from the subject’s viewpoint.

  2. For instance, Friston, who is at the origin of the predictive coding framework, sometimes appears to take prediction to be synonymous to beliefs, as shown here: “This surprise depends upon (prior) expectations, but where do these prior beliefs come from?” (2013, 213). The objective of this paper, however, is not to offer a detailed analysis of the predictive coding approach.

  3. One can explain the analgesic effect in the latter case by the fact that attention is then focused on the environment, and thus, away from one’s body. By contrast, one can predict fear of bodily damage (which is not tested here) to induce hyperalgesia.

  4. More generally, Klein (2018) argues against the predictive coding theories that the mind cannot be only a predictive machine if predictions are belief-like because there need also to be desires, preferences, and motivational states in general for the organism to act: “Try to get by with only prediction, and you’ll end up just sitting there” (Klein, 2018, p. 2542). See also Arpaly and Schroeder (2013). Advocates of predictive coding, however, want to collapse the distinction between beliefs and desires with the help of the notion of active inference (e.g. Clark, 2020; Hohwy, 2018). To summarize, Klein claims that predicting that you will be hungry will not suffice to make you eat, but Clark replies that it will in association with the prediction that you will no longer be hungry if you eat. It is not clear, however, that one can fully explain away conative states. For the sake of this paper, I shall not go further into the debate, since the notion of pain anticipation exists independently of the predictive coding framework.

  5. One may reply that such a case of emotional recalcitrance does not suffice to prove that there is no anticipatory pain belief insofar as one can entertain contradictory beliefs (Pendoley, 2023).

  6. These effects cannot be explained exclusively in attentional terms. The processing of peripersonal space keeps its unique signature even when attention is shifted away from the hand that receives the somatosensory stimulus and when participants focus on the contralateral side (Zanini et al., 2021). Still, these effects can hardly qualify as cognitive penetration. The impact of nociceptive prediction on pain appears to be closer to multisensory interaction.

  7. Grahek (2001) describes what he calls threat hypersymbolia: as soon as something or someone approaches his arm, a patient made brisk withdrawal movements and reports experiencing a burning pain (Hoogenraad et al., 1994). Similar behaviours can be found in patients with chronic pain (Moseley & Vlaeyen, 2015).

  8. Finally, one can also mention Klein’s (2015a) two-layer account, which distinguishes between pain itself, and painfulness, or what he calls suffering. On his view, painfulness, is not constitutive of pain; it is a distinct attitude taken towards pain. Within this framework, he then defends a body-directed imperative account for pain (e.g. “Don’t put weight on your ankle!”), and a higher-order imperative account for suffering (“Less of this pain!”).

  9. One may wonder whether the imperative content should be more detailed and contextually anchored, specifying exactly the kind of movements to perform given the exact threat. However, the imperative view does not assume that nociceptive prediction takes over motor planning and motor control. It simply claims that it directly provides to the motor system the end to achieve. The specific means to achieve this end are computed by the motor system, which anchors the bodily command to the situation and which organizes the information into action schemas hierarchically organized (Jeannerod, 1997).

  10. However, we cannot fully rule out that the imperative content could explain both effects.

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Acknowledgements

I would like to thank Hilla Jacobson and Luca Barlassina for their extremely useful comments on previous versions of this paper.

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  1. Institut Jean Nicod, CNRS—EHESS—ENS—PSL University, 29 rue d’Ulm, Paris, 75005, France

    Frederique de Vignemont

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de Vignemont, F. Expecting pain. Synthese 202, 156 (2023). https://doi.org/10.1007/s11229-023-04394-x

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