The Missing P in Psychiatric Training

Abstract

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 presently included in psychiatric residency training. Objective Our objective is twofold: (1) to provide clinical and scientific rationale for psychiatric training enrichment with basic tenets of pain medicine and (2) to raise the awareness and sensitivity of clinicians, scientists and educators alike to the important yet unmet clinical and public health need. Results Three lines of translational research evidence, extracted from the comprehensive literature review, are presented in support of the objective. First, the neuroanatomical and functional overlap between pain and emotion/reward/motivation brain circuits 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, pain may serve as a functional probe for unraveling pathophysiological mechanisms inherent in psychiatric morbidity given its stressful nature for the organism. Conclusions Pain training in psychiatry will not only contribute to deeper and more sophisticated insights into pain syndromes but also into psychiatric morbidity at large regardless of patients’ pain status. Furthermore, it will ease artificial boundaries separating psychiatric and medical formulations of brain disorders, thus fostering cross-fertilizing interactions between specialists in various disciplines entrusted with the care of pain patients.

Pain and suicidality: Insights from reward and addiction neuroscience

“…Similarly to pain and addiction that are two other conditions associated with erratic supraphysiological dopamine surges in the limbic system (Elman et al, 2011), aberrant salience in suicidality limits the behavioral repertoire and creates habit- rather than value-based rigid motivational states (Miranda et al, 2012) fixated on suicide-related content, in contravention to its devastating outcome and with diminution of mesolimbic neurons’ ability to detect signals for normal salience (social rewards) and loss of normal modulation of reinforcers’ values by non-suicidal contexts (Rangel et al, 2008). Suicidal urges may be further enhanced owing to the hypofunctional PFC (including the anterior cingulate) (Matthews et al, 2012) involved in the inhibitory control over obviously inappropriate acts (including processing their inappropriateness) involved in taking one’s own life (Dombrovski et al, 2012).…”

Generalized Anxiety Disorder: A Review of Recent Findings

“…27 Pain is an underestimated phenomenon in psychiatric patients in general, and in anxiety disorders including PTSD, although pain and anxiety are closely related entities. 28 Chronic neuropathic pain, affecting a large portion of elderly people, is strongly associated with depression and anxiety. Chronic pain often preceded a diagnosis of GAD in a German population-based study.…”

The role of fMRI in drug development

“…It is also well known that stimulus-dependent potentiation, as well as attenuation, occurs in CNS structures and circuits mediating not only sensory aspects of pain, but also affective and motivational ones [127,128]. It can be argued that the nonsensory components of pain are just as crucial as the sensory aspects of pain in driving the overall experience of pain and lowering quality of life [129]. In fact, in imaging studies of patients with chronic pain, the function of regions such as the nucleus accumbens [130], insula [131,132], and cingulate [133] have been shown to correlate with the level of reported clinical pain or disease-specific pain (e.g., knee movement in patients with knee osteoarthritis).…”