Explain Pain: beyond your DIM-SIM inventory

First post, Affective Somatics

You already did the difficult part

If you have been through Explain Pain, an outpatient pain programme, or a physiotherapist who took the time to teach rather than treat, you arrived somewhere genuinely useful. You learned that pain functions as a protective output rather than a readout of tissue damage. You learned that the body carries specialised interoceptive receptors that respond to molecular patterns and contribute to an immune set point, and that this set point shifts (Moseley & Butler, 2017). Very likely you met DIM-SIM, Danger in Me and Safety in Me, and you made a list.

That work holds. Nothing here asks you to give it up. This post is about what sits next to it, and about what my hands are actually doing when you are on the table.

Five patterns, unequal evidence

Moseley and Butler (2017) describe five associated molecular patterns that the interoceptors respond to: pathogen-associated (PAMPs), damage-associated (DAMPs), xenobiotic-associated (XAMPs), behaviour-associated (BAMPs) and cognition-associated (CAMPs).

The first three rest on well-characterised immunology, particularly the toll-like receptor pathways (Akira et al., 2006). BAMPs carry substantial cross-species behavioural and receptor evidence (Nesse & Ellsworth, 2009). When the environment carries danger, the body prepares at a molecular level, danger transmission increases, cardiac output and blood distribution shift, and the brain subsequently registers an emotion. That preparation operates as an intensive modulation of affective systems already coupled to pain neurochemistry (Panksepp & Biven, 2012).

CAMPs occupy a different position. Moseley and Butler (2017) introduce them under a heading that names the move as speculative (p. 60) and reason analogically from adjacent findings toward a prediction. Their candour about this is worth respecting.

Here is the consequence worth noticing. The pattern with the most operational attention in the pedagogy is the one its own authors flag as speculative. The pattern with the strongest evidence, BAMPs, receives the least sustained intervention.

What an inventory does, and where it stops

DIM-SIM asks you to sort exposures into categories: things people say, things you say, things you think and believe, things happening in your body, and people in your life.

Listing is a signifying operation. It takes a condition, gives it a name, assigns it a valence, and files it. Where the item genuinely is a belief, this works, and it works well. Revising “my disc is crumbling” measurably changes what the body prepares for, and I refer people to good pain education for exactly this reason.

BAMP-level conditions respond differently to the same operation. Writing my landlord on a list names the landlord. The preparation your body makes when the letterbox opens carries on at its own rate. The inventory can be completed. The readiness has no completion point, because it answers to conditions rather than to descriptions of conditions.

Accuracy is the point

Where housing is insecure, where a workplace is unsafe, where a partner is volatile, where medical dismissal has been repeated across years, the molecular preparation is correct. The body is doing arithmetic, and getting it right.

The perceived injustice literature makes this legible. Perceived injustice names the recognition that one’s pain followed from preventable conditions for which nobody was held accountable (Sullivan et al., 2008). It predicts life satisfaction more strongly than pain catastrophising does (Sturgeon et al., 2017), it tracks racialised differences in reported pain intensity (Trost et al., 2019), and it correlates with perceived childhood neglect (Ziadni et al., 2020). Imaging locates the associated plasticity in pathways loaded under sustained stress rather than under momentary appraisal (Kosek et al., 2021).

Asking someone to reclassify accurate danger as a thinking error costs them something, and often costs more than the pain relief it offers. Working affirmatively at the BAMP register begins by conceding the arithmetic.

What this register does respond to

BAMP-level operation remains fully available to intervention. It answers to inputs of a different kind: duration, pressure, weight, rate, sustained contact, temperature, breath, and the arrangement of a room.

Conditioned pain modulation is the clearest documented example. Applying a strong stimulus at one site produces diffuse inhibition of nociceptive processing elsewhere, a principle operationalised therapeutically for centuries through acupuncture, deep tissue work, shiatsu and manual pressure (Marchand, 2012). Conditioned pain modulation is reliably impaired in nociplastic conditions such as fibromyalgia and chronic widespread pain (Yarnitsky, 2015), and it is restorable. Four weekly sessions of manual therapy restored central pain processing in chronic neck pain, with attenuated temporal summation alongside it (Lascurain-Aguirrebeña et al., 2024). Two weeks of electroacupuncture repaired conditioned pain modulation in knee osteoarthritis where one week did not (Yu et al., 2020).

Touch carries its own chemistry. Repeated stimulation of C-tactile afferents increases oxytocin receptor density, releases dopamine and endogenous opioids, and brings practitioner and client autonomic rhythms into synchrony (McParlin et al., 2022). Intranasal oxytocin augments conditioned pain modulation efficiency (Goodin et al., 2012). The relational quality of the encounter alters the body’s inhibitory capacity materially, with a single session of empathetic interaction enhancing both conditioned pain modulation and manipulation-induced analgesia relative to neutral interaction (Muhsen et al., 2020).

Density matters more than intensity. In longitudinal massage work, twice-weekly sessions produced a large effect size for oxytocin increase while once-weekly produced negligible effects (Rapaport et al., 2012, as cited in Vigotsky & Bruhns, 2015). Restoration accumulates.

In the room

Myotherapy here means sustained pressure held long enough to become a duration rather than an event, and movement taken through range without a test attached to it. I am interested in what the tissue does over ninety seconds, not in what you can prove in five.

Zenthai Shiatsu transfers weight through sustained contact, works with breath and with sequences that move a whole body rather than a site. You stay clothed. We work on a mat rather than a table, and the treatment includes passive movement, traction and stretch.

Neither modality asks you to rate anything, report a number, or narrate the history again. The room is built deliberately with minimal clinical signification, because clinical apparatus generates its own nocebo load (Moseley & Butler, 2017). Fabrics, lighting, temperature and sound are all part of the treatment rather than the décor.

What sits alongside this

This does not replace pain education, your GP, physiotherapy, medication or psychological support. It does not claim that thinking has no role. It claims that the register where behaviour-associated preparation happens is reachable, and that it is reached by composition rather than by explanation.

That composition extends past the session. The photographs people take, the notebooks they keep, the walks they repeat, the music they put on at three in the morning: these operate at the same register, and I treat them as part of the work rather than as coping strategies.

Cadence

I suggest four to six weekly sessions before we review anything, because the evidence for restoration at this register is cumulative. A single session tells us how your system responds. A month tells us whether the modulatory capacity is shifting.

Bookings and current availability are on the affective somatics page. If you have a pain programme behind you and a sense that the list did not reach the thing, that sense is worth taking seriously.