No. Chronic pain is real, never imagined. Pain always involves the brain and nervous system, and the International Association for the Study of Pain (IASP) describes pain as a personal experience shaped by biological, psychological and social factors. IASP also says that a person's report of pain should be respected.
In chronic pain, the nervous system can amplify pain beyond what any tissue damage would explain. Spine scans also show changes in many people who have no pain at all, so a normal test does not show that pain is imagined, and an abnormal one does not always explain it. Stress, sleep and mood are closely linked with chronic pain, which is one reason psychological treatment has a place alongside medical care.
What pain is
IASP's 2020 definition of pain begins with the words "an unpleasant sensory and emotional experience," and IASP's terminology page gives it in full. The definition allows that experience to be linked to actual or potential tissue damage, or simply to resemble an experience linked to such damage.
Six notes follow the definition, and one of them separates pain from nociception, the nervous system's detection of potentially harmful events. Nociception can happen with no pain felt at all, so pain cannot be read from the activity of sensory nerves alone. By the field's own definition, pain without visible damage is still pain.
When to see a physician first
Some signs call for emergency or urgent medical care before anything else.
Call 911 or go to the nearest emergency department if you have a headache and any of the following applies, as listed on the UK National Health Service's headaches page:
- You have had a seizure (fit).
- You have numbness or weakness in the body or face.
- The headache started suddenly and is extremely painful.
- You have had a head injury within the last 3 months, for example from a fall or accident.
- You are finding it difficult to speak, balance, walk or remember things.
- You are drowsy or confused.
- You have loss of vision.
- You have a rash that does not fade when a glass is rolled over it.
- You have a very high temperature, a stiff neck, or bright lights are bothering you.
The CDC's stroke signs page also says to call 911 right away for a sudden severe headache with no known cause.
See your physician promptly if you have a headache and any of the following applies:
- You have vision or eye problems.
- The headache is triggered or made worse by coughing, sneezing, bending down or exercising.
- You are being sick (vomiting).
- You have jaw pain when eating or a sore or tender scalp.
- You have any other symptoms you're worried about.
Make an appointment with your physician if you have headaches on 15 or more days a month for more than 3 months, a new kind of headache, or a change in your usual pattern.
For back pain, the UK National Health Service's back pain page lists the signs that need emergency care. For bowel symptoms, the National Institute of Diabetes and Digestive and Kidney Diseases lists anemia, rectal bleeding, bloody or black tarry stools, and weight loss as warning signs that may point to another condition, so raise them with your physician. Psychological care for pain works alongside medical care, so take any other new, changing or unexplained symptom to your physician first.
Three kinds of pain
IASP's terminology describes three kinds of pain by what drives them, and all three are processes in the body and nervous system. Nociceptive pain arises from actual or threatened damage to body tissue other than the nerves. Neuropathic pain is caused by a lesion or disease of the somatosensory nervous system, the nerves and pathways that carry bodily sensation. The third kind, nociplastic pain, arises from altered processing of pain signals without clear evidence of tissue damage or of disease in those nerves, and one person can have it alongside nociceptive pain.
This third kind is often widespread or more intense than any identifiable tissue or nerve damage would explain, and it often comes with fatigue and with problems in sleep, memory and mood. It can occur on its own, as in fibromyalgia and tension-type headache, or alongside other pain, as in chronic low back pain, according to a 2021 review in The Lancet by Fitzcharles and colleagues.
Central sensitization and centralized pain
Central sensitization is one nervous-system process thought to contribute to pain of this kind. A 2011 review in Pain by Woolf defines it as an increase in the excitability of nerve cells in the central pain pathways, which shows up as heightened sensitivity. A light touch can hurt, and pressure can hurt more than expected. Woolf proposed that it contributes to conditions including fibromyalgia, osteoarthritis and headache. IASP notes that in the clinic it can only be inferred indirectly, from signs such as this heightened sensitivity.
In a 2026 Psychology Today interview, I described central sensitization as one reason the brain can keep generating pain without ongoing damage. My own studies use a related term, centralized pain.
When chronic pain is a condition in its own right
ICD-11, the latest International Classification of Diseases, defines chronic pain by duration alone, as pain that lasts or keeps coming back for more than 3 months. It sorts chronic pain into seven groups, as a 2019 IASP task-force paper in Pain by Treede and colleagues describes. One group, chronic primary pain, covers pain that lasts or recurs beyond 3 months, comes with significant emotional distress or interference with daily function, and is not better accounted for by another chronic pain condition. Chronic widespread pain and irritable bowel syndrome are examples, and a companion 2019 paper by Nicholas and colleagues notes that the diagnosis can be made without identifying a specific biological or psychological cause.
Words you may meet online
Readers who know Pain Reprocessing Therapy may have met the term neuroplastic pain, which writing about that method uses for a similar idea. It is not one of IASP's terms or an ICD-11 diagnosis. Older psychological-sounding labels such as "psychosomatic" can be heard as saying that symptoms are put on or imagined, as a 2002 article in the BMJ by Stone and colleagues notes. IASP's current terms describe how pain arises, and none of them means imagined.
What tests can and cannot show
Test results cannot settle whether pain is real. You may have sat in an exam room and heard that every test came back normal while the pain went on, and scans can also find changes that may have nothing to do with the pain.
Changes on spine scans are common in people with no back pain, and they become more common with age. A systematic review published in 2015 by Brinjikji and colleagues pooled 33 articles on spine imaging in 3,110 people without back pain. The estimated share with disk degeneration rose from 37% at age 20 to 96% at age 80, while disk bulges rose from 30% to 84% and disk protrusions from 29% to 43%. The authors concluded that many such findings are likely part of normal aging.
For low back pain, the American College of Physicians advised in 2011 that imaging be used only for severe or progressive nerve deficits or signs of a serious underlying condition. Otherwise, it found, routine imaging adds no clinically meaningful benefit and can cause harm. In its authors' words, "more testing does not equate to better care."
Because central sensitization can only be inferred indirectly, a normal scan can rule out some causes of pain without showing that nothing is wrong. Your physician is the right person to weigh any result against your symptoms and examination, and emergency signs always come first.
How stress and emotion relate to pain
Stress and strong emotion are closely linked with chronic pain. In "Danger, Not Damage," a 2026 article in Psychotherapy Bulletin, I describe how persistent pain can be read as the nervous system signaling danger. I present attachment as one contributor among many, alongside genetics, injury, stress, learning, and medical and social factors.
A sense of injustice about one's pain is a link with strong evidence behind it. A 2020 systematic review in Pain Medicine by Carriere and colleagues drew on 31 studies of 5,969 patients with musculoskeletal pain (literature searched through May 2019). Perceived injustice was associated with higher pain intensity and with poorer daily and physical function, evidence the authors rated as strong. Most of those studies measured both at the same time, so they cannot show which comes first.
What my research has found
In a 2024 study in The Journal of Pain, my coauthor and I studied 673 Black, Latine and Asian American adults with self-reported chronic pain. Those who reported more stressful life events also reported more centralized pain symptoms and higher pain intensity. Anger and a sense of injustice statistically accounted for part of the link with centralized symptoms and all of the link with pain intensity.
A 2026 research letter in the Journal of General Internal Medicine looked at race-based discrimination in a 2023 online survey of Black, Latine and Asian American adults in the United States with self-reported chronic pain. With stressful life events taken into account, the link between race-based discrimination and centralized pain symptoms ran statistically only through anger and a sense of injustice. Because both papers measured everything at one point in time, they describe associations in these groups and cannot show what causes what. In the 2024 paper we suggested that psychological treatment for centralized pain could target anger and perceived injustice, an idea the study did not test. My research page lists my other work.
What changes in the brain when pain improves
When chronic pain improves with treatment, brain activity can change with it, though the findings so far are modest and come from one trial. A 2022 randomized trial in JAMA Psychiatry by Ashar and colleagues assigned 151 adults with primary chronic back pain in Boulder, Colorado, in 2017 and 2018 to Pain Reprocessing Therapy, an open-label placebo injection or usual care. The therapy group had one evaluation and education session with a physician, then eight individual therapy sessions of about an hour over four weeks. Afterward, 66% of that group (33 of 50) were pain-free or nearly pain-free, compared with 20% with placebo and 10% with usual care.
The method's developers ran this single-site trial in a mostly White community sample with low-to-moderate pain. Because it compared the therapy only with a placebo and usual care, it cannot show how the therapy compares with other active treatments. Brain scans after treatment showed lower responses to provoked back pain in the anterior midcingulate and anterior prefrontal cortex compared with placebo, and in the left anterior insula compared with usual care, effects the authors called modest. Researchers are still working out what brain changes like these mean for recovery.
What psychological treatment works on
The therapies I use work on how people respond to pain, stress and emotion. In my practice, Emotional Awareness and Expression Therapy (EAET) leads. It helps people work through past stressors and emotions they have learned to avoid, which its developers see as keeping the nervous system in a state of threat, and Does EAET Work? reviews its trials.
Pain Reprocessing Therapy combines education about how the brain and nervous system produce pain with guided practice in reappraising pain sensations, so that they provoke less fear. I completed the Pain Reprocessing Therapy Center's Foundational (Level I) training, and I draw on that method for chronic pain. Attachment-oriented psychodynamic therapy informed by ISTDP (intensive short-term dynamic psychotherapy) looks at long-standing patterns in how people relate to themselves and to others, such as self-criticism and the pull to keep pushing through. My approach explains how the three fit together.
Cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) are the psychological therapies that England's 2021 NICE guideline names for chronic primary pain. It advises clinicians to consider either and found no basis for preferring one. The best fit depends on your symptoms, what you have tried and the kind of work that suits you.
Chronic pain in Washington and the US
Chronic pain is common nationally: in the 2025 National Health Interview Survey, 20.7% of US adults regularly had chronic pain, meaning pain on most days or every day in the past 3 months. In the West census region as a whole, which includes Washington, the figure was 18.3%.
I see adults with chronic pain, migraine and chronic headache by secure video anywhere in Washington, and in person on Fridays at my office in Lynnwood. I work with high-achieving people who are used to solving hard problems, until their bodies stop cooperating. Chronic pain is the center of my clinical work. I also work with migraine and chronic headache, and Can Therapy Help Migraines? reviews the research on them. The practice is private pay, and current fees are on Services and Fees.
When to see a psychologist
It makes sense to see a psychologist who works with chronic pain once pain has lasted or kept returning for more than 3 months (12 weeks), alongside your physician's check for disease or injury. It also makes sense when pain has begun to shape your work, sleep or relationships, or when worry, low mood, anger or fear of the pain itself has grown around it. How to find a chronic pain psychologist covers what to ask.
Frequently asked questions
What does chronic pain feel like?
Chronic pain varies from person to person, and IASP describes every kind of pain as both a sensory and an emotional experience. When the nervous system amplifies pain, a light touch can hurt and pain can spread across several areas, often with fatigue and trouble with sleep, memory and mood. Your physician can sort out what lies behind your own symptoms.
Can chronic pain lead to depression?
Chronic pain and depression often occur together, and the large studies that show this cannot say which comes first. A 2025 meta-analysis in JAMA Network Open by Aaron and colleagues pooled 376 studies from 50 countries, published from 2013 to 2023 and mostly of people in clinical care. It found clinically significant depression symptoms in 39.3% of adults with chronic pain and anxiety symptoms in 40.2%. If low mood has come with your pain, tell your physician.
How do you know if pain is all in your head?
No test can show that pain is imagined: pain is a personal experience that cannot be read from nerve activity alone, and a clinician's task is to work out what is driving it. A physician looks first for disease or injury, through your history, an examination and any tests that warning signs call for. Clinicians also look for signs that the nervous system is amplifying pain, such as pain that is widespread or more intense than any damage would explain, and those signs can sit alongside tissue damage in the same person.
How do doctors test for chronic pain?
No blood test or scan detects chronic pain itself, so doctors diagnose it from how long the pain has lasted, its pattern and an examination, and they use tests to look for other causes. A 2025 review I coauthored in Biology found no biomarker that identifies chronic pain and cautions against treating biomarkers as proof that it exists.
What is the most common chronic pain condition?
Low back pain is the most burdensome pain condition worldwide. The Global Burden of Disease study ranks it first among all causes of years lived with ill health and estimated that 619 million people had it in 2020.
What is it like living with chronic pain?
Living with chronic pain often reaches well beyond the body. In the same Psychology Today interview, I described chronic pain as amplifying the rest of life: worry and low mood feed each other, thinking gets foggy, people pull back socially, identity erodes, and spiritual questions arise. As I put it there, "Healing must be whole-person, addressing the mind and spirit alongside the body." A 2024 CDC data brief by Lucas and Sohi found that in 2023, 34.9% of US adults with chronic pain had high-impact chronic pain, which limited life or work activities on most days or every day.
What is the relationship between anxiety and chronic pain?
Anxiety and chronic pain often go together, though, as with depression, the surveys cannot show which comes first. A 2024 analysis of national survey data in Pain by De La Rosa and colleagues found that in 2019, 23.9% of US adults with chronic pain had current anxiety or depression symptoms, against 4.9% of adults without chronic pain.
If you would like to talk about your pain and how I work, the first step is a free discovery call.
About the author
Joel Jin, PhD, is a licensed psychologist in Washington who works with adults with chronic pain, migraine and chronic headache. He sees clients by secure video anywhere in Washington and in person on Fridays in Lynnwood. He is Associate Professor of Counseling Psychology at The Seattle School of Theology & Psychology, the author of more than 20 peer-reviewed articles, and a coauthor of two books on deliberate practice from the American Psychological Association.
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