Expanding neurobiological frameworks of resilience in chronic pain: the role of allostatic-interoceptive overload

Expanding neurobiological frameworks of resilience in chronic pain: the role of allostatic-interoceptive overload | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 4 February 2026 V1 Latest version Share on Expanding neurobiological frameworks of resilience in chronic pain: the role of allostatic-interoceptive overload Author : Yuri Cordeiro SZEREMETA 0000-0002-5068-9665 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.177020120.06845706/v1 205 views 71 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Resilience has been most frequently defined as a coalescence of factors that promotes positive adaptations despite adversities. Conceiving resilience as an active psychophysiological process in chronic pain management can guide evidence-based clinical practices, promoting better outcomes for patients. Traditional models partially address the multilevel and transnosological aspects of chronic pain, particularly the interactions between interoception, allostasis, and resilience. Encouraging further debates in the field, this theoretical article synthetizes recent evidences that suggests a synergy between these three phenomena, highlighting them as key modifiers of the neurobiology and phenomenology of chronic pain, and offers a comprehensive understanding of how resilience mechanisms work in conjunction with bodily perception and stress modulation systems. Expanding neurobiological frameworks of resilience in chronic pain: the role of allostatic-interoceptive overload Yuri Cordeiro SZEREMETA 1* 1 PostGraduate Program in Neuroscience, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil. *Corresponding author information: Yuri Cordeiro Szeremeta ( [email protected] ). ORCID 0000-0002-5068-9665. Postgraduate Program in Neuroscience, Universidade Federal de Santa Catarina, 88040-900, Florianópolis, SC, Brazil. Phone: +55 48 3721 4617. Abstract Resilience has been most frequently defined as a coalescence of factors that promotes positive adaptations despite adversities. Conceiving resilience as an active psychophysiological process in chronic pain management can guide evidence-based clinical practices, promoting better outcomes for patients. Traditional models partially address the multilevel and transnosological aspects of chronic pain, particularly the interactions between interoception, allostasis, and resilience. Encouraging further debates in the field, this theoretical article synthetizes recent evidences that suggests a synergy between these three phenomena, highlighting them as key modifiers of the neurobiology and phenomenology of chronic pain, and offers a comprehensive understanding of how resilience mechanisms work in conjunction with bodily perception and stress modulation systems. Keywords: Chronic pain; Interoception; Resilience; Allostatic overload; Allostasis; Stress. Abbreviations: Anterior Cingulate Cortex, ACC; Chronic pain, CP; Default Mode Network, DMN; functional Magnetic Resonance Imagery, fMRI; Nucleus Accumbens, NAc; Ventral Tegmental Area, VTA. Total word count without References: 2.782 words. Total figure count: 1 Total table count: 1 Introduction Resilience was defined by a set of cognitive coping strategies that mitigate the effects of stressful experiences (Rutter, 1985). Building upon Rutters’ seminal work, which was further developed by others (Lavretsky et al., 2026; Udeh-Momoh et al., 2025; Harrison et al., 2025; Farchi & Peled-Avram, 2025; Waugh & Sali, 2023), resilience could be described as a dynamic ability that people adapt and thrive under adversity, encompassing psychophysiological and sociocultural aspects aimed at well-being maintenance. The phenomenon involves the allostatic-interoceptive system, and therefore, the allostatic-interoceptive overload (i.e., the cumulative strain on the body that results from repeated cycles of anticipatory biological changes adapted to prepare the body for potential needs and stress (Santamaría-García et al., 2024)). The concept is profoundly related to adaptation of acute or chronic stress, and it’s therefore intricated in the neurobiology and phenomenology of Chronic Pain (CP) (Sturgeon et al., 2024). CP represents a highly prevalent disease and a complex challenge for global health systems (Zimmer et al., 2022; Blyth & Schneider, 2018). The condition is classified as a chronic disease by the International Classification of Diseases (ICD-11) when the pain persists beyond the acute period (≥ 3 months), surpassing the average healing time (Treede et al., 2019). According to a recent update on the definition of pain by the International Association for the Study of Pain (IASP) (Raja et al., 2020), CP is an inherently personal and unique experience shaped by multifactorial biopsychosocial interactions. Despite extensive research, its etiology and pathophysiology remain only partially understood, largely due to the complex interplay of sensory, emotional, and cognitive dimensions. Through this short communication article, it is hypothesized that maladaptive changes in the allostatic-interoceptive system may be crucially involved in causing failures in resilience capacity, ultimately leading to the chronicity and maintenance of pain. Our purpose is to introduce a body of evidence that illustrates the resilience from this pathophysiological perspective and demonstrate how the allostatic-interoceptive synergy manifests within the complex framework of the CP experience. Interoception: anatomical trails and clinical implications in Chronic Pain As an avant - garde topic in Neuroscience emerging evidence highlights the influence of interoceptive information on multiple systems (Schoeller et al., 2024). In the context of pain, previous research has suggested mechanisms through which interoception contributes to pain modulation via homeostasis (Craig, 2014). Interoception is define as the interpretation and integration of internal bodily signals, processed at both conscious and non-conscious levels (Suksasilp & Garfinkel, 2022). The ability to access, recognize, and respond to these internal signals is fundamental for maintaining homeostasis (Berntson & Khalsa, 2021; Quigley et al., 2021; Craig, 2014). Interoceptive signals are typically categorized into three main types: biochemical (e.g., pH, organic molecules, peptides, neurotransmitters, hormones), mechanical (e.g., tissue stretching, nerve-ending deformation), and thermal/electromagnetic signals (e.g., thermoreceptor activity, nerve conduction) (Chen et al., 2021). Berntson & Khalsa (2021) and Barrett (2017) describe the anatomical pathways mediating transduction, transmission, and integration of interoceptive signals conveyed by Aδ fibers, C fibers, and the vagus nerve. These inputs converge hierarchically at the insula-cingulate hub, a key node representing bodily afferents and homeostatic regulation. Interoceptive signals include respiratory, cardiovascular, gastrointestinal, and genitourinary signals, as well as thermoception, proprioception, nociception, body awareness and, symptom perception (Desmedt et al., 2024). While distinctions exist between interoception and exteroception (Toussaint et al., 2024), interoception must be understood in interaction with exteroceptive signals (Engelen et al., 2023). Finally, the phenomenon can be studied across three dissociable domains: accuracy (i.e., performance on objective tests of bodily signals detection); sensibility (i.e., subjective assessment of internal sensations via questionnaires or interviews); and awareness (i.e., correspondence between objective interoceptive accuracy and subjective report) (Garfinkel et al., 2015). Interestingly, a recent meta-analysis by Horsburgh et al. (2024) advanced our understanding, showing that CP sufferers exhibit lower interoceptive accuracy and higher interoceptive sensibility. These experimental findings underscore the importance of interoception in the pathophysiology and symptomatology of CP, and can be considered a cornerstone in a set of new theoretical derivations (Garfinkel & Eccleston, 2025; Bannister et al., 2025; Szeremeta, 2026). However, how are changes in body perception systems linked to stress modulation systems in people with chronic pain? Phenomenological frameworks: Resilience, interoception and pain Due to its different domains, resilience should be understood as a mosaic rather than a monolithic phenomenon, covering: biological (e.g., brain reserve, multiomics, genetic/epigenetic); cognitive (e.g., education, cognitive stimulation, occupational complexity); psychological (e.g., coping strategies, self-regulation, self-knowledge, self-efficacy, optimistic self-perceived future); and social domains (e.g., family bonds, positive social connections, intergenerational knowledge) (Farchi & Peled-Avram, 2025; Udeh-Momoh et al., 2025). Resilience measurement comprises different psychometric tools, surrounding psychological attribute factors (e.g., commitment, challenge, control, self-efficacy, optimism, positive self-image), process factors (e.g., anticipation, reactivity, adaptability), and outcome factors (e.g., positive outcome) (Huerzeler et al., 2025). Risk factors of vulnerability in resilience can be exemplified by lifespan childhood, family, community, and environmental adversities, as well as personal and psychological challenges, such as emotional distress, mental health disorders, and pain catastrophizing (i.e., a repertoire of behaviors characterized by rumination, magnification, and helplessness) (Wolke et al., 2025; Wilson et al., 2025). Altogether, the key components of resilience align with environmental factors involved in the development of CP (Tanguay-Sabourin et al., 2023), with the well-established different dimensions of pain (i.e., affective-motivational, sensory-discriminative, and cognitive-evaluative) (De Ridder et al., 2022), and finally, with the development and maintenance of allostatic-interoceptive overload (Santamaría-García et al., 2024)—a concept explored in the following section. From a developmental perspective and accordingly with recent findings reported on CP sufferers, higher levels of resilience were positively associated with pain acceptance, better daily and physical function, engaging in valued life activities despite pain, reduced likelihood of experiencing any CP, lower likelihood of co-morbid mental health disorders (e.g., anxiety, depression), better psychological response towards nociception and reduced need for analgesia. Also, low levels of resilience were positively correlated with poor self-regulation, impaired psychosocial functioning, the accelerated biological aging, pain at multiple sites, pain disability, and intensity (Rogers et al., 2025; Kinnie Davis et al., 2025; Wilson et al., 2025; Zelčāne & Pipere, 2024 ; Loduca et al., 2024; Chng et al., 2023 for scoping review). Although considerable research has explored resilience in CP, a still growing field of research investigates the relationship between changes in different interoceptive domains and clinical manifestations in CP patients— Table 1 summarizes recently published data in this regard. Colgan & Parman (2024) CP in general; 301 patients (48% females); 18–70 years. To investigate the relationships among self-report measures of adaptive body awareness, central sensitization related symptoms, and pain intensity among individuals with chronic pain; Cross-sectional; interoceptive awareness. Interoceptive awareness has been shown to partially mediate the relationship between sleep disturbances and pain, with increased sleep disruption predicting higher pain intensity and lower interoceptive awareness. Colgan et al. (2022) CP in general; 280 patients (48% females); mean age 45 years. To investigated the relationships between perceived sleep disruption, pain interference, pain intensity, and interoceptive awareness; Cross-sectional; interoceptive awareness. Individuals with higher bodily awareness reported lower pain intensity and reduced central sensitization. Todd, Plans, et al. (2024) Fibromyalgia; 154 patients (100% females); mean age 42.13 years. To examine cardiac interoceptive accuracy in adults with fibromyalgia and symptom impact; Cross-sectional; interoceptive accuracy. Patients with high interoceptive accuracy experienced reduced symptom impact, linking interoceptive accuracy with disease severity. Lin et al. (2024) CP in general; 250 patients (55% females); mean age 36.87 years. To examine whether patients with CP would exhibit less differentiated perception and mental representation of emotional feelings and bodily states; Cross-sectional; interoceptive accuracy. Patients perceived greater and more pervasive similarities between emotional feelings and bodily states, associated with lower subjective interoceptive accuracy. Agostinho et al. (2025) Fibromyalgia; 29 patients (100% females); mean age 50.41 years. To investigate the relationship between interoception and cognition in fibromyalgia. Exploratory analysis; interoceptive accuracy. Patients with a lower ability to accurately perceive bodily signals, particularly on the cardiac modality, may have difficulties using these key signals to direct cognitive abilities. Oliveira et al. (2024) Chronic musculoskeletal pain (84% females); 173 patients. To identify profiles of interoceptive sensibility skills among individuals with CP and examined their associations with pain outcomes and psychological and behavioral risk or protective processes; Cross-sectional; Interoceptive sensibility. Individuals with low interoceptive sensibility skills reported low self–efficacy, and higher catastrophizing and kinesiophobia. Conversely, those with higher interoceptive sensibility skills, when compared with the mixed interoceptive sensibility skills group, performed better in carrying out their daily life activities in pain, and presents high somatic focus and higher fear that pain signals would represent potentially serious injury. Table 1. presents a summary of studies that investigated how different domains of interoception (i.e., sensitivity, accuracy, awareness) are linked to clinical manifestations in the experience of CP. Based on biological plausibility, it can be considered that the findings listed below involve mechanisms of changes in resilience capacity, characterized by a set of maladaptive changes resulting from allostatic-interoceptive overload. Neurobiological frameworks and mechanistic explanations Emerging models in clinical neuroscience integrate complex world-brain-body dynamics, proposing an inextricable link between interoception and allostasis (Santamaría-García et al., 2024; Ibanez & Northoff, 2024; Ibanez et al., 2024). Allostasis is the process that maintains homeostasis through ongoing interoceptive feedback, enabling adaptation to present and future scenarios (Sennesh et al., 2022). Just as the process is based on anticipated environmental demands (i.e., predictive processes), the anticipatory nature of the allostatic-interoceptive system applies to physiology, emotions, behavior, and cognition (Schiller et al., 2024; Sennesh et al., 2022). The synergy between interoception and allostasis, as shown in recent theoretical and neuroimaging studies, is crucial for understanding the complex interplay between environmental contingencies/demands and various pathophysiological pathways (Ibanez & Northoff, 2024; Santamaría-García et al., 2024). Providing structural evidence for these theoretical frameworks, Zhang et al. (2025) recently mapped a large-scale allostatic-interoceptive system, showing the involvement of cortical (e.g., insula, ACC), and subcortical regions (e.g., mediodorsal thalamus, lateral geniculate nucleus, hippocampus, dorsal amygdala, NAc, superior colliculus, substantia nigra, VTA). With a central role for the ACC and insula, interoception involves allostatic regulation and the anticipation of bodily needs in relation to environmental conditions (Engelen et al., 2023). Guided by this formulation, which emphasizes a complex allostatic-interoceptive synergy, disruptions in these dynamics may lead to systemic imbalances. For instance, diseases that induce allostatic-interoceptive overload, such as CP (Del Mauro et al., 2025; Liang & Booker, 2024; Rabey & Moloney, 2022; Lunde & Sieberg, 2020; Timmers et al., 2019), may provoke pathological changes, including metabolic and parasympathetic dysregulation, neurotransmission imbalances, and numerous structural brain changes (volume and density) (Lenart-Bugla et al., 2022; Liang & Booker, 2024; Santamaría-García et al., 2024; Tracy et al., 2016; Zeng et al., 2025). When the system is overloaded, dysregulation leads to imbalances that affect the perception of pain and the appropriate response to stress, facilitating and perpetuating CP and allostatic overload. In CP, biological stressors of allostatic overload can be exemplified by some biomarkers, including: neuroendocrine (e.g., cortisol, epinephrine, norepinephrine, dehydroepiandrosterone); immune (e.g., C-reactive protein, interleukin-6, fibrinogen); metabolic (e.g., high-density lipoprotein, hemoglobin A1c, total cholesterol, body mass index rate variability, elevated systolic and diastolic blood pressure) (Borsook, 2025, Fillingim et al., 2025); in gut dysbiosis (Goudman et al., 2024); and finally, by common clinical manifestations such as central sensitization and impaired resilience (Borsook, 2025; Wallden & Nijs, 2021 ). Figure 1 presents a synthesis of these theoretical frameworks. Figure 1. (a) a set of stressful events across lifespan can either attenuate or intensify allostatic-interoceptive processes, expressed by biological responses to environmental demands (e.g., cardiovascular, endocrine, immune, metabolic, dysbiosis) (b); (c) the cytoarchitecture of the allostatic-interoceptive network connects bodily signals to a range of cognitive domains and emotional processing; (d) Chronic stress leads to a breakdown of physiological functions (e.g., disrupted communication, hyper or hypoactive system) outside a functional physiological range; (e) as a result of the allostatic-interoceptive overload, insufficient resilience keeps the state in a chronic state of difficult recovery from stress, causing accelerated aging, disease and death. Figure partially created with BioRender.com. Towards mechanistic explanations of CP and resilience, preliminary evidence indicates the involvement of the three canonical circuits of pain: the Default Mode Network (DMN), the salience network, and the central executive network (De Ridder et al., 2022). For instance, data collected in CP patients shows a significant negative association between the resilience and within-network connectivity of DMN, as well as a positive association between the resilience and between-network connectivity involving the DMN and salience network (Jarrahi et al., 2023). Furthermore, there was a significant negative association between the interoceptive awareness —attention regulation domain— and within-network connectivity of DMN, as well as between interoceptive awareness —emotional awareness domain— and DMN within-network connectivity of the central executive network (Jarrahi et al., 2023). Also in CP patients, greater stress resilience is associated with decreased activity, reactivity, and functional connectivity within salience network structures (e.g., insula, ACC), and amygdala (Sturgeon et al., 2024 for scoping review). The assumption of interoceptive correlation with resilience is also supplemented by data collected in individuals without CP. For example, in healthy participants who underwent a resting-state fMRI session, resilience was associated with stronger insula-precuneus, insula-cerebellum, and insula-prefrontal networks; and interoceptive awareness was linked with stronger intra-insula, insula-striatum, and insula-motor networks (Fermin et al., 2024). These data are in line with a previous systematic review that identified the insula as one of the structures involved in resilience in a mentally healthy population. Additional structures are exemplified by the orbitofrontal cortex, ACC, and amygdala (Tai et al., 2023). Also in healthy participants, Haase et al. (2016) demonstrate that individuals with lower resilience show reduced attention to bodily signals — interoceptive awareness — but greater neural processing to aversive bodily perturbations — higher insular and thalamic activation. The authors state that in low-resilience individuals, this mismatch between attention and processing of interoceptive afferents may result in poor adaptation in stressful situations. These data are in agreement with results of recent meta-analysis by Izagirre et al. (2026), that revealed a negative association between interoceptive accuracy —evaluated by the heartbeat counting task performance— and physiological stress responses. One possible additional mechanistic explanation that links resilience and interoception appears to be the heart-rate variability, as h igher heart-rate variability indicates robust emotional regulation capabilities and resilience to stressors (Guendelman et al., 2024), and in CP patients, this variability is generally low (Tracy et al., 2016, for meta-analysis). With regard to the brain structures highlighted in the neuroimaging findings mentioned above, it is possible to infer a correlation between resilience and the brain structures that make up the allostatic-interceptive system mapped by Zhang et al. (2025). To substantiate this assumption, it is necessary to emphasize that there is a plethora of structural (Zeng et al., 2025), and functional brain changes observed across the three canonical networks of CP, citing: Salience (Fiúza-Fernandes et al., 2025; Johansson et al., 2024); Default Mode (Cavicchioli et al., 2025; Fiúza-Fernandes et al., 2025; Zhu et al., 2024; Johansson et al., 2024); and the Central Executive (Del Mauro et al., 2025; Castejón, Chen, et al., 2024; Yasoda-Mohan & Vanneste, 2024; Hechler et al., 2016; Löffler et al., 2022; De Ridder et al., 2021). From a synergy between the allostatic-interoceptive system and resilience, the theoretical framework presented aims to broaden understanding of the neurobiology and phenomenology of chronic pain, seeking to connect the dots between psychophysiological states and the subjective experience of pain. Finally, to improve lifestyle changes and resilience, some strong evidence-based key points of clinical orientation in CP, may mitigate the negative impact of or confer successful adaptation to pain, such as: encouraging the practice of physical activity and mind-body therapies—highlighting the improvement of interoception here (Núñez-Cortés et al., 2025; Gnall et al., 2024); the dietary optimization (Elma et al., 2022); the promotion of cognitive engagement and pain education (Moseley et al., 2024); the enhancement of optimism (Basten-Günther et al., 2019); the benefit-directed of stress reduction (Vachon-Presseau, 2018); the increase of social support (Rinaudo et al., 2025); the orientation of the benefits associated with spiritual care (Perrin et al., 2025); and the importance of improve sleep quality (Duo et al., 2023). Conclusion The relationship between the environment, body, and brain influences the experience of pain through an allostatic-interoceptive synergy. To the best of our understanding, the impaired resilience capacities in CP patients appear to be a result of a breakdown of this synergy. Recognizing these intricated mechanisms highlights the importance of coping strategies in CP management, aimed at interrupting maladaptive cycles surrounding sensory-cognitive-affective-emotional domains. The frameworks outlined in this review may also be relevant for informing clinical guidelines on psychotherapeutic approaches, pain education, and body–brain integration practices, focusing on restoring patients’ bodily perception, sense of agency, and stress and pain modulatory systems. Data Availability Statement None. Statement of acknowledgement This research was financially supported by grants from Brazilian funding agency: Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). Also, I would like to express my gratitude to my PhD advisor, Eduardo Luiz Gasnhar Moreira PhD, for giving me complete freedom of thought and research. Conflict of interest statement The author has no financial or personal conflict of interest related to this work. Author contributions statement The conception of the work, bibliographic research, data acquisition and interpretation, and original draft was written by Y.C.S. All content was subsequently reviewed and edited by the author, who take full responsibility for the final text and its accuracy. References Agostinho, M., Capelas, M. L., Pimentel-Santos, F. M., & Canaipa, R. (2025). Disentangling interoception and its links to cognitive functioning in fibromyalgia. Scientific Reports , 15 (1). https://doi.org/10.1038/s41598-025-15087-5 Bannister, K., Patel, R., & Hughes, S. (2025). The descending modulation of pain. In Pain (Vol. 166, Number 11). https://doi.org/10.1097/j.pain.0000000000003683 Barrett, L. F. (2017). The theory of constructed emotion: an active inference account of interoception and categorization. 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