What a Family Medicine Physician Wants You to Know About Neuroplastic Pain and the Vagus Nerve
By Dr. Lienna Wilson, Licensed Psychologist | Vagus Vitality
Chronic pain, fatigue, and digestive symptoms are often assumed to mean something is structurally wrong. But a growing body of clinical work shows that the nervous system itself can learn to produce and sustain real physical symptoms, even after tests come back clear. Understanding that process, and the vagus nerve's role in helping the body come out of it, can open up a path forward when a standard workup reaches a dead end.
To learn more about this topic, I reached out to Dr. Rita Gupta, a family medicine physician board-certified in both Family Medicine and Integrative Medicine. She completed her residency at Mayo Clinic and a fellowship through the Andrew Weil Center for Integrative Medicine, and she now has advanced-level training in Pain Reprocessing Therapy and Emotional Awareness and Expression Therapy. Her own history with persistent pain shaped much of how she now helps patients understand the relationship between the nervous system and their symptoms, so I asked her to walk through how she explains that connection, what treatment actually looks like, and where the vagus nerve fits in.
What Neuroplastic Pain Actually Means
Dr. Gupta starts in the same place every time. "The first thing I tell people is that all symptoms are 100% real," she says. "Neuroplastic does not mean imagined, exaggerated, or all in your head. It describes the brain's capacity to learn protective patterns, and, in some cases, safer ones over time."
She explains that the brain and nervous system are constantly taking in information from the body and deciding what needs attention. Pain, in that sense, is doing its job. "If you touch a hot stove, pain is exactly what you want your nervous system to produce, because it helps protect you from injury." The trouble comes when that same protective system becomes over-tuned. "In some chronic pain conditions, the nervous system can become highly sensitized and begin interpreting ordinary sensations as more threatening than they are, by processing and amplifying signals." Fear, attention, avoidance, past experience, and learned association can all reinforce that pattern, and the body can start associating pain with specific triggers. "One may begin to associate sitting, bending, exercise, a particular environment, or even a certain time of day with pain," she notes.
Dr. Gupta is also clear that this framework does not replace medical evaluation. Mixed conditions, where neuroplastic changes and structural or physical contributors coexist, are common, and new, changing, severe, or progressive symptoms should always be assessed medically first. "Negative testing also does not mean nothing is wrong, or that the symptoms are not real or deserving of care and attention," she says. "It means the evaluation hasn't found a particular structural or disease process that fully explains the picture." For fatigue and digestive symptoms especially, she finds it more useful to widen the lens rather than narrow it. "I usually frame it more as, what factors are contributing to what this person is experiencing. That wider lens is often much more useful alongside their medical treatment."
Hypervigilance, Vagal Tone, and Getting Stuck in Fight or Flight
"I use the word hypervigilance carefully," Dr. Gupta says, "because it does not always look like someone consciously feeling anxious." More often, it shows up as bracing, scanning the body, anticipating symptoms, constantly checking in, difficulty resting, or a persistent internal pressure to keep everything under control.
When the nervous system reads a signal, internal or external, as a threat, it mobilizes. "It can increase heart rate, muscle tension, changes in breathing, altered digestion, sweating, changes in sleep, or heightened awareness of bodily sensations," she explains. The healthy version of this system moves in both directions. "We need mobilization when something requires action, and we also need the capacity to settle, digest, connect, rest, and recover."
This is where the vagus nerve comes in. "The vagus nerve, also known historically as the pneumogastric nerve, is an important part of the parasympathetic system, bringing the body back to balance," Dr. Gupta says. But she is careful not to reduce regulation to any single nerve or technique. "Supporting vagal function can be very useful. Regulation as a whole-system capacity: the ability to respond to challenge and then return toward safety, connection, and recovery, rather than focusing on any single pathway alone." This connects to what is sometimes described in the polyvagal literature as the autonomic nervous system's capacity to shift flexibly between defensive and socially engaged states depending on cues of safety and threat (Porges, 2009).
Flexibility, not calmness, is what Dr. Gupta is really tracking with patients. "Can the nervous system respond to a challenge and then settle again? Can someone feel activation without interpreting it as an emergency? Can they notice uncertainty, emotion, or a physical sensation without immediately needing to eliminate it? That capacity to move between states matters more to me than trying to stay calm all the time." She also points out how invisible this pattern can become. "People don't even recognize how activated they are, because it has become their baseline. Someone may be rushing, speaking quickly, clenching, anticipating, or focusing entirely outward, and simply experience that as normal."
Inside a Pain Reprocessing Therapy Session
Pain Reprocessing Therapy, or PRT, is used when a clinician has evaluated the symptom pattern and has reason to believe neuroplastic mechanisms are contributing. A randomized controlled trial of PRT in patients with chronic back pain found that 66% of participants randomized to the treatment were pain-free or nearly pain-free at posttreatment, compared with 20% on placebo and 10% on usual care, with gains largely maintained at one-year follow-up (Ashar et al., 2022). "It helps someone change how the brain interprets and responds to pain in that context," Dr. Gupta says.
A typical session includes psychoeducation, exploring the person's symptom patterns, identifying fear and learned associations, and helping the person build a different relationship with bodily sensation. One of the best-known PRT tools is somatic tracking. "Rather than immediately trying to escape, fix, or analyze the sensation, we bring attention to it with curiosity," she explains. Someone might notice where a sensation sits, whether it feels like pressure, warmth, tingling, tightness, aching, or pulsing, whether it has a clear edge, and whether it moves, expands, or contracts.
The quality of that attention is what matters most. "Fearful monitoring asks questions at that sound urgency: is it getting worse, why is it still here, what does this mean, is this exercise working," Dr. Gupta says. "Somatic tracking is more like: this is what I notice right now, interesting, it is moving, there is pressure here, I do not have to decide what that sensation means immediately." Somatic tracking works through three components: mindful attention, safety reappraisal, and a touch of positive affect or lightness. Crucially, the goal is not to make pain drop in the moment. "If someone finishes the exercise and says my pain is still a five, so I did it wrong, then somatic tracking has become another way to monitor symptoms," she says. "Most often, the first change is not that the pain disappeared. It may be that the sensation is still there, but I identify with it less. Over time, this becomes a meaningful shift and often turns the volume down on pain signals."
PRT also addresses conditioned responses, the learned expectation that certain movements or activities will bring on pain. "We may gradually create corrective experiences that allow the nervous system to learn something new," Dr. Gupta says. "We do not force that process. In fact, we want to trust the process." When direct attention to a sensation feels overwhelming, the pace slows down. "Exposure should create a tolerable opportunity for new learning, rather than simply overwhelming the person. The goal is not to promise symptom elimination, but to reduce fear, expand capacity, and support quality of life."
What Emotional Awareness and Expression Therapy Looks Like
Emotional Awareness and Expression Therapy, or EAET, has its own evidence base. A cluster-randomized trial found EAET matched cognitive behavioral therapy and an education control on most outcomes for people with fibromyalgia, while showing an edge on measures like widespread pain and the percentage of patients achieving meaningful symptom reduction (Lumley et al., 2017). "EAET helps people become more aware of emotions they may have learned to avoid, minimize, suppress, or feel unsafe expressing," Dr. Gupta says. "That might include anger, grief, fear, sadness, shame, disappointment, or needs that have not had much room."
She is quick to correct a common assumption about the therapy. "An important misconception is that EAET means there must be some hidden trauma or repressed emotion that caused the symptoms, and if we uncover it, the symptoms will disappear. That is not how I approach it. We do not need to go hunting for trauma, and we do not want emotional work to become another recovery assignment where someone thinks, what emotion am I missing, or what have I failed to uncover."
Instead, the questions she asks tend to be simpler. "What am I actually feeling? What happens inside me when I feel anger? Do I allow myself to feel disappointment? Can I recognize what I need? Do I automatically move away from certain emotions?" Dr. Gupta sees this pattern often in capable, high-functioning people. "Many people have learned very adaptive ways of functioning. They may be excellent at caring for others, anticipating what people need, keeping the peace, being productive, or pushing through. But sometimes that comes at the expense of recognizing their own emotional experience. Emotional work allows us to reconnect." She's careful to frame the goal correctly. "That does not mean emotion is the sole cause of symptoms. It means emotions are part of normal human physiology and can influence our nervous system, muscle tension, attention, behavior, and how we experience our bodies. The goal is greater emotional flexibility and capacity, not perfect emotional control."
Dr. Gupta's Own Path to This Work
"My experience changed the way I understood pain, both personally and professionally," Dr. Gupta says. As a physician, her early training was built around finding pathology. "I had spent years learning to look for pathology, identify disease, rule out danger, and treat what was wrong in the body. That training is incredibly important, and I still believe deeply in appropriate medical evaluation." But her own experience with persistent pain, alongside years of watching patients continue to suffer, revealed the limits of a purely structural lens.
"I learned firsthand how quickly life can become organized around pain," she says. "You begin paying attention to what hurts. You start noticing what makes it better or worse. You may become afraid of movement or certain activities. You begin anticipating symptoms before they happen. You wonder whether someone missed something. And very naturally, your world can become smaller."
What shifted things for her was understanding neuroplasticity itself. "What helped me was understanding that the nervous system can learn, and, therefore, can also learn differently. That gave me a much more integrated view of healing." Her questions with patients changed accordingly. "I am not simply asking what is wrong with your body. I am also curious about what the nervous system has learned, what has become associated with danger, what happens when symptoms appear, whether there is fear, monitoring, or uncertainty, whether there are patterns of internal pressure or self-criticism, what emotions are present, what the person needs, and what parts of their life have gradually disappeared because symptoms have taken up so much space." Her own experience also changed how she talks to patients. "Hearing that it is just stress can be profoundly invalidating. The pain is real. The physiologic changes are real. Understanding the nervous system does not make those symptoms less biological. It gives us a broader understanding of biology."
A Common Misconception About Mind-Body Medicine
"Probably the biggest misconception is that if the brain or nervous system influences my symptoms, then they must not be real," Dr. Gupta says. "They are real. There is no imaginary version of pain. The brain is involved in every experience of pain, because pain is ultimately an experience the nervous system creates in response to information from the body, the environment, memory, prediction, attention, and context."
The second misconception she runs into is the opposite kind of oversimplification. "Mind-body medicine means stress causes everything. I do not believe that. New or concerning symptoms deserve appropriate medical evaluation. Sometimes there is structural pathology. Sometimes there is disease. Sometimes biological factors are involved that we do not yet fully understand. Sometimes neuroplastic mechanisms, nervous system sensitization, fear, attention, conditioning, emotion, and behavior also contribute. More than one thing can be true."
Above all, she wants patients to hear this work without hearing blame. "I also want people to understand that they did not create this by worrying too much, having the wrong personality, failing to regulate their nervous system, or not processing their emotions correctly. That quickly turns mind-body medicine into blame. We're not looking for what you did wrong. We are becoming curious about what your brain and body may have learned, and where there may now be opportunities for new learning. That shift matters.
Where to Start: Nervous System Regulation at Home
Dr. Gupta starts by reframing the goal itself. "I am less interested in teaching people the perfect tools to regulate their nervous system, and more interested in helping them build the capacity to notice what is happening and respond with greater flexibility." Timing and individual fit matter as much as the technique itself. "We don't want to use the tools with urgency or pressure. Otherwise, nervous system regulation can become another source of pressure. Did I breathe enough? Did I meditate correctly? Why am I still activated? Why am I still symptomatic? Sometimes healing becomes another place where we feel like we have to get an A."
Her favorite starting point is what she calls micropractices, small enough to fit into an ordinary moment. "One is simply pausing and noticing what is happening right now. Am I rushing? Am I bracing? Are my hands clenched? Am I monitoring my body? Am I putting pressure on myself?" She points to the STOP practice used in mindful compassion training as one simple version of this.
Breath and grounding are next, but only when they feel natural rather than forced. "I might invite someone to notice their breath, or let the exhale soften slightly." For people who find it hard to turn attention inward right away, she often suggests starting outside the body instead.
"Feel the chair underneath you. Notice your feet on the floor. Look outside. Listen to a sound. Feel warmth from a cup of tea. Notice something beautiful." She also likes to lower the bar for what counts as progress. "Looking for very small shifts, even one percent more support, rather than demanding that the whole body feel calm." Movement has a place too, depending on someone's medical situation and capacity. "Walking, stretching, yoga, dancing, rocking, humming, or simply changing position can be useful."
Finally, she encourages a habit of checking in emotionally. "What am I feeling? What do I need? Maybe I need rest. Maybe I need movement. Maybe I need a boundary. Maybe I need connection. Maybe I need to cry. Maybe I need to stop researching symptoms for tonight." And sometimes, she says, the answer has nothing to do with healing at all. "Music, laughter, a friend, nature, creativity, or something meaningful can all matter."
If you’ve been struggling with persistent pain or symptoms that don’t show up clearly on tests, there is a path forward that doesn’t require choosing between mind and body. As Dr. Gupta puts it, "the goal is not to spend our whole lives regulating our nervous systems. It is to develop enough flexibility, trust, and capacity to return more fully to our lives."
About Dr. Rita Gupta: Dr. Rita Gupta is a family medicine physician board-certified in Family Medicine and Integrative Medicine. She completed residency training at Mayo Clinic and fellowship training through the Andrew Weil Center for Integrative Medicine with Dr. Andrew Weil. She has advanced-level training in Pain Reprocessing Therapy and Emotional Awareness and Expression Therapy and is a certified mindfulness and meditation teacher. She helps people with chronic pain and persistent symptoms understand the role of the nervous system in their experience and rebuild a safer relationship with their body. To learn more, visit bodyandmindapproach.com.
Note: Pain Reprocessing Therapy and Emotional Awareness and Expression Therapy are typically delivered by a trained clinician as part of a broader treatment plan, and neuroplastic pain frameworks are not a substitute for medical care. New, changing, severe, or progressive symptoms should always be evaluated by a qualified medical provider. Nothing here is a substitute for individualized care and should be discussed with your own healthcare provider.
References
Ashar, Y. K., Gordon, A., Schubiner, H., Uipi, C., Knight, K., Anderson, Z., Carlisle, J., Polisky, L., Geuter, S., Flood, T. F., Kragel, P. A., Dimidjian, S., Lumley, M. A., & Wager, T. D. (2022). Effect of pain reprocessing therapy vs placebo and usual care for patients with chronic back pain: A randomized clinical trial. Journal of the American Medical Association Psychiatry, 79(1), 13–23. https://doi.org/10.1001/jamapsychiatry.2021.2669
Lumley, M. A., Schubiner, H., Lockhart, N. A., Kidwell, K. M., Harte, S. E., Clauw, D. J., & Williams, D. A. (2017). Emotional awareness and expression therapy, cognitive-behavioral therapy, and education for fibromyalgia: A cluster-randomized controlled trial. Pain, 158(12), 2354–2363. https://doi.org/10.1097/j.pain.0000000000001036
Lumley, M. A., & Schubiner, H. (2019). Emotional awareness and expression therapy for chronic pain: Rationale, principles and techniques, evidence, and critical review. Current Rheumatology Reports, 21, 30. https://doi.org/10.1007/s11926-019-0829-6
Porges, S. W. (2009). The polyvagal theory: New insights into adaptive reactions of the autonomic nervous system. Cleveland Clinic Journal of Medicine, 76(Suppl 2), S86–S90. https://doi.org/10.3949/ccjm.76.s2.17