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The Missing P in Psychiatric Training:  Why It Is Important to Teach Pain to Psychiatrists

Igor Elman, MD; Jon-Kar Zubieta, MD, PhD; David Borsook, MD, PhD
Arch Gen Psychiatry. 2011;68(1):12-20. doi:10.1001/archgenpsychiatry.2010.174.
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Context  Pain problems are exceedingly prevalent among psychiatric patients. Moreover, clinical impressions and neurobiological research suggest that physical and psychological aspects of pain are closely related entities. Nonetheless, remarkably few pain-related themes are currently included in psychiatric residency training.

Objectives  To provide clinical and scientific rationale for psychiatric-training enrichment with basic tenets of pain medicine and to raise the awareness and sensitivity of physicians, scientists, and educators to this important yet unmet clinical and public health need.

Results  We present 3 lines of translational research evidence, extracted from a comprehensive literature review, in support of our objectives. First, the neuroanatomical and functional overlap between pain and emotion/reward/motivation brain circuitry suggests integration and mutual modulation of these systems. Second, psychiatric disorders are commonly associated with alterations in pain processing, whereas chronic pain may impair emotional and neurocognitive functioning. Third, given its stressful nature, pain may serve as a functional probe for unraveling pathophysiological mechanisms inherent in psychiatric morbidity.

Conclusions  Pain training in psychiatry will contribute to deeper and more sophisticated insight into both pain syndromes and general psychiatric morbidity regardless of patients' pain status. Furthermore, it will ease the artificial boundaries separating psychiatric and medical formulations of brain disorders, thus fostering cross-fertilizing interactions among specialists in various disciplines entrusted with the care of patients experiencing pain.

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Figure 1.

Schematic overview of the interface between neurobiological and psychological factors involved in the experience of chronic pain. Several lines of evidence link pain to emotional, motivational, and reward processing. At the frontocingulate cortical level, chronic pain conditions may cause brain reorganization via glutamatergic mechanisms, resulting in emotional and cognitive impairments with ensuing negative affective states and compromised decision-making capacity. Dysphoric emotional states render pain stimuli more aversive, leading to additional psychological impairments. With regard to subcortical systems, acute pain is associated with increased dopaminergic trafficking within mesolimbic dopaminergic pathways. Chronic pain exerts an opposite action by decreasing dopaminergic transmission in the same neural structures and is accompanied by decreased motivation toward normally pleasurable stimuli.

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Figure 2.

Pain and emotions. A, Pain produces changes in emotional states with ensuing psychiatric symptoms. These effects are bidirectional; that is, negative affective states can augment the perceived intensity of pain. B, Altered sensation and functional changes in brain regions that subserve emotional states and cognition. Adapted from Borsook et al.32

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Figure 3.

Schematic diagram of potential mechanisms involved in drug-related motivational changes during adequate treatment, undertreatment, or overtreatment of pain with opioid analgesics. A, Pain relief due to adequate analgesia restores the homeostatic equilibrium and seldom produces addiction. Dependence on opioid analgesics, including tolerance and withdrawal, is more likely and calls for a gradual and judicial dose escalation. B, Inadequately treated or untreated pain activates dopaminergic ventral striatal neurotransmission involved in motivational processing, leading to heightened incentive salience attribution to pain and pain-related stimuli. Although this state is viewed as a pseudoaddiction rather than a genuine one, the latter's features may predominate with time, causing opioid overuse in the form of attempts to self-medicate perceivably intolerable pain and pain-related anxiety. C, Changes in the mesolimbic dopaminergic circuitry induced by opioids, taken at doses exceeding the homeostatic need for pain alleviation, may be responsible for transforming regular motivational drives into heightened incentive salience assigned to opioids or opioid-related cues. An additional critical aspect of opioid overuse in the context of an ongoing pain condition is the amplification of the physical and emotional aspects of pain. Such cross-sensitization is typical of addictive substances and entails a situation in which prior exposure to one stimulus increases the subsequent response to itself and to a different stimulus.

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