By Justine Framularo | Licensed Mental Health Counselor and Biofeedback clinician, MA, LMHC, HMIP
If you live with chronic pain, you already know that it’s more than just a physical sensation. It can color your entire world—shaping your mood, your relationships, your sleep, and even the way you think about yourself and your future. What many people don’t realize, though, is that chronic pain often has as much to do with what’s happening in the brain and nervous system as it does with what’s happening at the site of injury.
As a clinician who specializes in somatic therapy, nervous system regulation, and the mind-body connection, I see this dynamic play out with my clients every day. The good news? Understanding how your brain creates and maintains pain feedback loops is the first step toward breaking free from them—and Cognitive Behavioral Therapy (CBT) is one of the most powerful, evidence-based tools we have to do just that.
Understanding Chronic Pain: More Than “Just” Tissue Damage
Acute pain—the kind you feel when you stub your toe or burn your hand—serves an important protective function. It’s your body’s alarm system, alerting you that something is wrong so you can respond. In a healthy pain cycle, once the injury heals, the alarm turns off and the pain resolves.
Chronic pain is fundamentally different. While acute pain is a response to active tissue damage, chronic pain can persist long after tissues have healed—or in some cases, without any identifiable structural cause at all. Research published in the Cleveland Clinic Journal of Medicine describes how the central nervous system can undergo structural, functional, and chemical changes that make it more sensitive to stimuli, a process called central sensitization. In this state, the nervous system amplifies pain signals—essentially turning the volume up on pain even when the original cause has resolved.
According to data reported in the Cleveland Clinic Journal of Medicine, roughly one in five Americans lives with chronic pain that significantly impacts their daily life. Chronic pain is now recognized as a leading cause of disability globally, according to research published in The Lancet Rheumatology. These aren’t just statistics—they represent real people who are suffering, often without understanding why their pain persists.
The Brain’s Pain Feedback Loops: How the Alarm Gets Stuck
Here’s what neuroscience is teaching us: chronic pain is not simply a signal traveling from an injury site to the brain. It involves complex feedback loops between multiple brain regions, the spinal cord, and the peripheral nervous system. Over time, these loops can become self-reinforcing—meaning the brain continues to produce pain even in the absence of ongoing tissue damage.
The Pain-Emotion-Cognition Loop
Research in neural circuits and pain processing has identified that activity in corticostriatal and corticolimbic circuits plays a central role in whether acute pain transitions to chronic pain. In simpler terms: the brain regions responsible for emotions, memory, and decision-making become deeply intertwined with pain processing. This means that fear, stress, depression, and catastrophic thinking aren’t just consequences of chronic pain—they actively contribute to maintaining it.
A 2024 study published in Communications Biology describes this as a vicious cycle: chronic pain triggers negative emotional reactions, and those negative emotions further amplify the person’s pain perception, creating a repeating loop of pain–negative emotion–pain. The amygdala—the brain’s emotional processing center—and the prefrontal cortex—responsible for higher-order thinking and regulation—are both key players in this cycle.
Central Sensitization: When the Nervous System Turns Up the Volume
Central sensitization occurs when neurons in the central nervous system become hyperexcitable, responding more intensely to stimuli than they normally would. This can lead to allodynia (pain from stimuli that shouldn’t be painful, like light touch) and hyperalgesia (an exaggerated pain response to mildly painful stimuli). Research shows that the central nervous system can essentially “learn” pain through long-term plasticity changes. Persistent stimulation from an initial injury can cause pain-related brain regions to remain in a heightened state of excitability, creating what researchers describe as long-term potentiation of cortical synapses. Think of it like a well-worn path through the woods—the more the pain signal travels that route, the more established and automatic it becomes.
The Trauma Connection
There’s another layer to this story that is especially important in my practice: trauma. Research from a study of over 900 chronic pain patients found that 54% reported traumatic life events, and those with higher trauma severity showed greater pain widespreadness, sleep impairment, and emotional distress. Trauma and chronic pain share overlapping neural pathways, and unresolved trauma can keep the nervous system locked in a state of heightened arousal—making it much harder for the pain alarm to turn off.
How CBT Rewires the Brain’s Pain Response
Integrating CBT with Nervous System Regulation
At Heartfelt Healing Institute, I believe that the most effective approach to chronic pain combines the cognitive tools of CBT with somatic, body-based strategies that directly address the nervous system. While CBT works from the top down—changing thoughts to change feelings and physical responses—somatic approaches like biofeedback, breathwork, and nervous system regulation techniques work from the bottom up, helping the body learn to shift out of fight-or-flight and into a state of safety and regulation.
Research supports this integrated approach. A Frontiers in Molecular Neuroscience review notes that interdisciplinary approaches combining neuromodulation techniques with CBT show promise for disrupting the pain-emotion feedback loops that keep chronic pain entrenched. And neuroimaging research consistently shows that multi-modal treatment—pairing pain education with CBT—produces better long-term outcomes than either approach alone.
When we pair cognitive tools with body awareness and nervous system regulation, we address chronic pain at every level: the thoughts that fuel it, the emotions that amplify it, and the physiological patterns that sustain it.
Signs Your Nervous System May Be Stuck in a Pain Loop
If you’re wondering whether your chronic pain involves nervous system dysregulation or a brain-based feedback loop, here are some signs to look for: your pain persists long after an injury has healed, your pain seems to move around or spread to different areas of the body, light touch or mild stimuli cause significant pain, stress or emotional upset reliably worsens your pain, you experience fatigue, sleep disturbance, or brain fog alongside your pain, medical tests have come back “normal” but the pain is very real, and you notice a strong connection between your emotional state and your pain levels.
If any of this resonates, know that your pain is not “all in your head”—but your brain and nervous system are deeply involved in maintaining it. And that’s actually good news, because it means we have powerful tools to intervene.
Taking the First Step Toward Healing
Chronic pain doesn’t have to be a life sentence. Understanding the neuroscience behind your pain—the feedback loops, the central sensitization, the emotional amplification—is the first step toward reclaiming your life. CBT, especially when combined with somatic and nervous system–focused approaches, offers a path forward that addresses the whole person: mind, brain, and body.
If you’re living with chronic pain and feel stuck, I invite you to reach out. At Heartfelt Healing Institute, we take a compassionate, science-informed approach to healing that
honors both the physical reality of your pain and the nervous system patterns that may be maintaining it. You deserve more than just managing your pain—you deserve to understand it, and to have real tools to change it.
Heartfelt Healing Institute
Justine Framularo | MA, LMHC, HMIP
Specializing in Psychotherapy, Biofeedback, Somatic Therapy, & Trauma Treatment
401-584-2837 -215 Toll Gate Road, Suite 309 #13, Warwick, RI
Disclaimer: This blog post is for educational and informational purposes only and is not a substitute for professional medical or psychological treatment. If you are experiencing chronic pain, please consult with a qualified healthcare provider.
Works Cited
Baliki, M. N., & Apkarian, A. V. (2015). Nociception, pain, negative moods, and behavior selection. Neuron, 87(3), 474–491.
Dydyk, A. M., Chiebuka, E., Stretanski, M. F., & Givler, A. (2025). Central pain syndrome. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK553027/
Jensen, K. B., Kosek, E., Wicksell, R., Kemani, M., Olsson, G., Merle, J. V., Kadetoff, D., & Ingvar, M. (2012). Cognitive behavioral therapy increases pain-evoked activation of the prefrontal cortex in patients with fibromyalgia. Pain, 153(7), 1495–1503. https://doi.org/10.1016/j.pain.2012.04.010
Kuner, R., & Kuner, T. (2021). Cellular circuits in the brain and their modulation in acute and chronic pain. Physiological Reviews, 101(2), 619–718. https://doi.org/10.1152/physrev.00040.2019
Nijs, J., George, S. Z., Clauw, D. J., Fernandez-de-las-Penas, C., Kosek, E., Ickmans, K., Fernandez-Carnero, J., Polli, A., Kapreli, E., Huysmans, E., Cuesta-Vargas, A. I., et al. (2021). Central sensitisation in chronic pain conditions: Latest discoveries and their potential for precision medicine. The Lancet Rheumatology, 3(5), e383–e392. https://doi.org/10.1016/S2665-9913(21)00032-1
Rathod, S. S., Zhang, J., & Zhuo, M. (2025). Decoding pain chronification: Mechanisms of the acute-to-chronic transition. Frontiers in Molecular Neuroscience, 18, 1596367. https://doi.org/10.3389/fnmol.2025.1596367
Thorn, B. E. (2020). Putting the brain to work in cognitive-behavioral therapy for chronic pain. Pain, 161(Suppl 1), S66–S74. https://doi.org/10.1097/j.pain.0000000000001839
Volcheck, M. M., Graham, S. M., Fleming, K. C., Mohabbat, A. B., & Luedtke, C. A. (2023). Central sensitization, chronic pain, and other symptoms: Better understanding, better management. Cleveland Clinic Journal of Medicine, 90(4), 245–254. https://doi.org/10.3949/ccjm.90a.22019
Wiesenfeld-Hallin, Z., Xu, Q., & Zhuo, M. (2025). Cortical potentiation in chronic neuropathic pain and the future treatment. Pharmaceuticals, 18(3), 363. https://doi.org/10.3390/ph18030363
Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152(3 Suppl), S2–S15. https://doi.org/10.1016/j.pain.2010.09.030
Zhuo, M. (2025). Chronic pain and comorbid emotional disorders: Neural circuitry and neuroimmunity pathways. International Journal of Molecular Sciences, 26(2), 436. https://doi.org/10.3390/ijms26020436