The power to adapt: How resilience and changing expectations contribute to placebo effects

Expectations about medical treatment are important prognostic indicators of treatment success and play a key role in shaping individual pain experiences. Placebo interventions can modify these expectations and promote pain relief. Resilience, a psychological trait implicated in pain recovery, has also been positively associated with placebo responsiveness. In this study, we tested the hypotheses that (1) pain resilience is negatively associated with pain interference, and (2) pain resilience is positively associated with placebo effects via reinforced expectations of analgesia. A total of 152 participants with chronic orofacial pain underwent a placebo intervention involving classical conditioning and verbal suggestion. Expectations of pain reduction were assessed both before and after the conditioning phase. Participants completed self-report measures, including the Pain Resilience Scale, Life Orientation Test-Revised, Pain Catastrophizing Scale, and Beck Depression Inventory-II. Analyses controlled for optimism, catastrophizing, depression, sex, race, and education. Pain resilience was negatively associated with pain interference (b = -0.930, t = -2.107, p =.037) and positively associated with reinforced expectations of analgesia (b = 1.176, t = 2.949, p =.004), controlling for psychological and demographic factors. Importantly, reinforced-but not baseline-expectations mediated the relationship between resilience and placebo effects (a*b = 0.03, bootstrapped 95% CI = 0.0003-0.0758). These findings suggest that the ability to revise expectations following a positive treatment experience, is a key mechanism linking resilience to placebo effects. Interventions that target both resilience-building and expectation updating may enhance treatment responsiveness in chronic pain. PERSPECTIVE: Pain resilience predicts lower pain interference and greater placebo analgesia by enhancing the ability to update expectations after positive treatment experiences. Reinforced but not baseline, expectations mediate resilience-related placebo effects, highlighting expectation updating as a key mechanism and potential target to improve treatment responsiveness in chronic pain.