Expectations of increased and decreased pain explain the effect of conditioned pain modulation in females

Espen Bjørkedal, Magne Arve Flaten

Department of Psychology, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway

Objective: Chronic pain is believed to be related to a dysfunction of descending pain modulatory mechanisms. Functioning of descending pain modulation can be assessed by various methods, including conditioned pain modulation (CPM). CPM refers to the inhibition of one source of pain by a second noxious stimulus, termed the conditioning stimulus. This procedure can activate an endogenous pain inhibitory mechanism that inhibits early nociceptive processing. Chronic pain and anxiety disorders are more prevalent among females and it has been hypothesized that females react with more negative emotions towards unpleasant stimuli and this might be part of the explanation of greater pain sensitivity in females. The present study investigated whether expectations modulate the effect of conditioning stimulation on pain, subjective stress, and heart rate. In addition, we investigated whether the modulation of CPM by expectations differed between males and females.
Methods: Seventy-two subjects (including 36 women) received six noxious heat stimuli to the forearm. During three of these stimuli, a conditioning stimulus (cold-water bath) was applied to the contralateral arm in order to activate CPM. One third of the subjects were told that this would reduce pain (analgesia group), one-third that it would increase pain (hyperalgesia group), and one third received no information about its effect (no info group).
Results: Information that conditioning stimulation decreased or enhanced pain had the corresponding effect in females, but not in males. Conditioning stimulation increased stress, but not heart rate in females in the hyperalgesia group. A higher expectation of analgesia and lower stress during conditioning stimulation was associated with larger inhibitory CPM.
Conclusion: These results suggest that reduced inhibitory CPM can be due to contextually induced cognitive and emotional factors and not necessarily a dysfunction of descending inhibitory pathways.

Keywords: pain, conditioned pain modulation, expectations, placebo analgesia, nocebo hyperalgesia