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, both chronic and acute, often interferes with sleep. Sleep interruptions and the side effects of pain medication are among the most commonly described disruptive interactions between pain and sleep. Bad dreams, which can be more difficult to study objectively than sleep disorders, are frequently associated with stress, anxiety, depression, and psychiatric and emotional disorders.

 Bad dreams are also associated with physical pain. The implications of this relationship are important, as bad dreams have been shown to have a substantial impact on sleep quality and restorative sleep. The disruptive effects of bad dreams can impact several important life issues, including mood, 

Recent research is beginning to shed a light on the complex relationships between pain and bad dreams. Postsurgical frightening dreams have been reported, especially among children.

 These dreams are thought to be short-lived, without a strong rate of recurrence, and are thought to be possibly associated with the effects of anesthesia, unfamiliar surroundings, and anxiety about surgery. Bad dreams during the perioperative timeframe are not thought to have a substantial impact on quality of life. Chronic pain, however, is also associated with bad dreams, and this can have more disruptive implications on day-to-day life.

Musculoskeletal pain, which is a particularly common type of pain, can develop as a result of serious injuries and associated 

 (PTSD), but it more often occurs in the absence of severe physical issues or associated psychological sequelae. A recent observational study published in 

 compared the frequency of self-reported bad dreams and nightmares between participants who had chronic musculoskeletal pain and a control group who did not have this type of pain. Over the course of a month, 44% of 191 participants with established pain reported bad dreams, compared to 7.3% of the 191 controls. The researchers also measured several other variables, including vitamin D and calcium levels, anxiety, and depression. Low vitamin D and calcium, as well as the presence of anxiety or depression, were all correlated with bad dreams and with musculoskeletal pain.

While the conclusions do not definitively point to a strong independent correlation between pain and pain bad dreams, these results do support the idea that there could be a possible connection.

Research has also examined the relationship between 

 and bad dreams. Migraines are widely considered to be complex experiences that include pain but are not limited to pain. Bad dreams are associated with 

, and the relationship seems to be bidirectional. Some small studies have suggested that bad dreams can occur during an ongoing migraine episode, and research also suggests that some people may have bad dreams prior to the onset of the painful portion of a migraine episode, possibly as part of a migraine prodrome.

The mechanism behind the relationship between pain and bad dreams is not fully established, but these types of 

 generally occur during the rapid eye movement (REM) sleep stage. Researchers suggest that the either the dream content is altered by pain experiences, or that the recollection or amount of REM sleep is altered by the physiological effects of pain on the brain.

 Understanding the mechanism can help guide treatment strategies. And, for some patients, their own awareness of the interactions between pain and their dreams can help encourage them to report their experiences and to seek treatment.

 and bad dreams have an impact on sleep quality, as well as on daytime sleepiness. Patients who experience chronic pain conditions, including migraine, often experience daytime fatigue and increased sleepiness around the time of the episodes. These symptoms are independent of sleep disturbance, but they can be exacerbated by sleep disturbances. Nightmares and bad dreams can further contribute to daytime sleepiness and diminished quality of life for people who are living with chronic pain. Patients who have bad dreams can experience anxiety about the dream content or may become concerned about whether the dreams are a reflection of their own mental health. These issues highlight the importance of adequate pain treatment for people who have pain conditions. Yet some medications can further interfere with sleep, making treatment less than straightforward.

Pain treatment can be intimidating for patients who are concerned about side effects and addiction. While these are valid concerns, there are many safe options for managing pain besides oral medication, including injections, patches, meditation, and cognitive behavioral therapy, among others. All of these can help alleviate the risk of bad dreams that can worsen sleep quality and quality of life for patients who have chronic pain.

is Associate Editor Humanities in Neurology, Clinical Assistant Professor Case Western Reserve University School of Medicine, Div. of Medical Education, and Editor in Chief Emeritus of 

1. Vanek J, Prasko J, Ociskova M, et al. 

Nightmares affect the experience of sleep quality but not sleep architecture: an ambulatory polysomnographic study.

3. Eriksson M, Nilsson U, Bramhagen AC, et al. 

Self-reported postoperative recovery in children after tonsillectomy compared to tonsillotomy.

Nightmares and bad dreams among individuals with musculoskeletal pain: a link to vitamin D and calcium.

Nightmares in migraine: a focused review.

Pain can have a substantial impact on sleep quality and quality of life. 

Pain on the Brain: The Relationship Between Bad Dreams and Chronic Pain

The US Food and Drug Administration (FDA) has approved Impel NeuroPharma’s Trudhesa (dihydroergotamine mesylate [DHE]) nasal spray for the acute treatment of migraine with or without aura in adults.

Trudhesa is the first and only therapeutic to use Impel’s proprietary precision olfactory delivery (POD) technology to deliver DHE quickly to the bloodstream through the upper nasal canal, thus offering rapid and sustained symptom relief without injection or infusion. Symptom relief is consistent even when administered long after the onset of a migraine attack.

“We are delighted with the approval of Trudhesa and are proud to offer the millions of Americans with migraine a non-oral, acute treatment option that may provide rapid, sustained, and consistent relief, even when taken late into a 

 attack,” said Adrian Adams, Chairman and Chief Executive Officer of Impel NeuroPharma. “The approval of TRUDHESA marks the culmination of more than a decade of research and advanced engineering to pair the proven efficacy of DHE with our innovative POD technology.”

In the phase 3, open-label, pivotal safety study, STOP 301, which is the largest longitudinal study ever conducted with DHE using nasal spray delivery, two-thirds of 360 participants with migraine had pain relief 2 hours after being treated with Trudhesa with more than 5650 migraine attacks treated. For 1 in 6 patients, pain relief started as early as 15 minutes.

 is a disease that impacts the whole body and is the second leading cause of disability,” said Kevin Lenaburg, executive director of the Coalition for Headache and Migraine Patients. “Historically there have not been enough effective treatments for treating migraine attacks, especially treatments that are not oral medicines, which can be challenging due to nausea, vomiting and other GI symptoms that can occur during a migraine. We welcome an important new treatment that combines the long-established efficacy of DHE with a non-oral, innovative delivery system that allows patients to self-administer wherever they are and at any point within a migraine attack.”

Stephanie J. Nahas-Geiger, MD, MSEd, Associate Professor in the Department of Neurology and Program Director of the Headache Medicine Fellowship Program at Thomas Jefferson University, commented: “Many of my patients need more from their migraine treatment, and TRUDHESA offers a non-oral, fast-acting, reliable option that overcomes many current medication challenges. Its upper nasal delivery circumvents the GI tract and common phenomena associated with migraine, such as nausea and gastroparesis, that can impact the effectiveness of oral treatments. And, importantly, it is a self-administered, single dose that can be taken anytime during a migraine attack, so patients don’t need to worry about missing the opportunity to benefit from using TRUDHESA within a certain timeframe. I think patients will be very receptive to this treatment, because it pairs the long-proven benefits of DHE with a patient-friendly delivery system.”

 are often comorbid with psychiatric disorders, especially mood and anxiety disorders.

 Although the exact nature of the comorbidity is unknown, several mechanistic hypotheses have been considered, including serotonergic dysfunction, ovarian hormone influences in women, and processes perpetuating central sensitization. Similarly, behavioral factors can influence the onset and course of headaches. 

The Commercial launch of TRUDHESA is planned for early October 2021.

1. Impel Neuropharma. Impel NeuroPharma announces US FDA approval of Trudhesa (dihydroergotamine mesylate) nasal spray for the acute treatment of migraine. News release. September 3, 2021. 

https://www.globenewswire.com/news-release/2021/09/03/2291459/0/en/Impel-NeuroPharma-Announces-U-S-FDA-Approval-of-TRUDHESA-Dihydroergotamine-Mesylate-Nasal-Spray-for-the-Acute-Treatment-of-Migraine.html

2. Smith TR, Winner P, Aurora SK, et al. 

STOP 301: a phase 3, open-label study of safety, tolerability, and exploratory efficacy of INP104, Precision Olfactory Delivery (POD®) of dihydroergotamine mesylate, over 24/52 weeks in acute treatment of migraine attacks in adult patients.

3. Smitherman TA, Penzien DB, Rains JC. Migraine and psychiatric comorbidity. 

 2013;(30)1. Accessed September 3, 2021. 

www.psychiatrictimes.com/view/migraine-and-psychiatric-comorbidity

The first and only treatment to use proprietary precision olfactory delivery technology to deliver DHE to the upper nasal cavity just received FDA approval. 

Nasal Spray for Treatment of Migraine Approved by FDA

The next time one of psychiatry’s detractors tells you that psychiatrists do not treat real diseases because we have not identified the precise pathophysiology of schizophrenia, bipolar disorder, or other psychiatric illnesses, try this: Ask the skeptic to explain the precise pathophysiology of migraine or cluster headaches. Follow up by asking what laboratory test or neuroimaging study neurologists use to diagnose these devastating conditions. At that point, the critic should be either blushing or blanching.

For the coup de grace, ask them why the late Thomas Szasz, MD—who insisted that real diseases always entail the identification of specific morphological or physiological abnormalities—did not write a book titled 

 as a sequel to his famous (or infamous) 1961 work 

. (Disclosure: Szasz was one of my teachers during residency and an intellectual 

—our mutually agreed-upon term—for decades afterward).

 readers will know that the precise pathophysiology of migraine and cluster headaches is not known, despite notable advances in our understanding; and that there is no laboratory test or neuroimaging study that reliably or usefully identifies 

 Both diagnoses are made largely on the basis of the patient’s subjective report and the exclusion of other neurological causes. (Cluster headaches are often, but not always, associated with ipsilateral cranial autonomic signs, such as eyelid edema or facial flushing).

 As for Szasz and migraines, to the best of my knowledge, he never disputed the reality of this affliction, even though its precise pathophysiology remains incompletely understood.

Let us take note of the excellent piece by journalist and headache sufferer Tom Zeller Jr, who 

 his own struggles with cluster headaches.

 Technically, these are a subset of a group of conditions known as the 

 (TACs). Although this hifalutin name may suggest that scientists have pinned down the etiology and pathophysiology of TACs, this is simply not the case.

To be sure, plausible theories abound, including, most recently, linking TACs to “dysfunction in the trigeminal and cranial autonomic systems and their connections, modulated by the hypothalamus.”

 Yet, as headache specialist Stephanie J. Nahas, MD, has acknowledged, “The pathophysiology of TACs is complex and incompletely understood.”

 And, as a rule, morphological and anatomical abnormalities in the brain are lacking in TACs; for example, investigation rarely yields abnormalities on magnetic resonance imaging or computed tomography imaging. (However, vascular loop compression and pituitary abnormalities are sometimes found in patients with short-lasting, unilateral neuralgiform headache attacks or SUNHA.

) Furthermore, to my knowledge, TACs are never noted on autopsy reports, contrary to Szasz’s erroneous claim that “Every ‘ordinary’ illness that persons have, cadavers also have.”

 may reasonably be applied to the TACs, which Nahas has called, “a distinct set of headache diseases.”

 This is so, even though, as Zeller rightly noted, “any neurologist working today will readily admit that we remain the in the Stone Age with regard to many aspects of these most common disorders.”

 may reasonably be applied to schizophrenia, bipolar disorder (BD), and other incapacitating psychiatric afflictions, even though the etiology and pathophysiology of these heterogeneous conditions are not yet well understood. There are, however, 

 showing a variety of morphological and physiological abnormalities in both schizophrenia and bipolar disorder.

By and large, physicians are a practical lot, anxious about evaluating everybody sitting in their overcrowded waiting rooms. Most physicians do not scratch their heads, pondering the question, “Will my next patient have a disease, a disorder, a malady, an illness, a morbus, an affliction, or a syndrome?” The subtle differences among these terms are of far less clinical importance than the presence of substantial and/or enduring suffering and incapacity in the patient—arguably, the hallmarks of disease (dis-ease) as commonly understood throughout the 

 (I am well aware that not all states of suffering and incapacity are ordinarily viewed as disease, including instances of torture, physical or psychological abuse, and the like).

Cluster headaches and related diseases certainly fit the criteria of substantial and/or enduring suffering and incapacity; indeed, cluster headaches are ominously known as 

 It hardly needs mentioning that serious psychiatric disease states like schizophrenia, BD, and various psychoses also produce substantial and/or enduring suffering and incapacity—and all too often lead to 

Citing the work of sociologist Joanna Kempner, PhD, Zeller noted that migraine headaches, in particular, “have been given inadequate consideration by the medical and scientific establishments,”

 which Kempner attributed partly to the disproportionate number of women afflicted by migraines. Ironically, Zeller noted, their physical pain “was often ascribed a psychological or emotional origin.”

Like the TACs described by Zeller, psychiatric disease is too often dismissed or disparaged, and psychiatric patients are often 

 Sadly, this is due in part to the influence of Szasz and others who have relegated psychiatric diseases to the status of myths, problems in living, or—as Szasz once argued—forms of lying.

Despite Szasz’s widespread influence, his ideas have come in for heavy criticism. For instance, psychiatrist Tony Benning, MBChB, MSC, MRCPsych, FRCPC, PhD, 

the views of another psychiatrist, R.E. Kendell, MD

As Kendell pointed out in his rebuttal of Szasz’s claim that mental illnesses fail to conform to the definition of disease, Szasz’s notion of disease, influenced by [Rudolph] Virchow, was overly narrow, for it placed excessive importance on the criterion of ‘cellular pathology.’ Kendell also claimed that Szasz’s argument understated the extent to which ‘suffering and incapacity are fundamental attributes of disease’. He brought attention to the fact that in medicine generally there is no universally agreed upon definition of disease, and if Szasz’s criterion were to be widely adopted, several diseases widely recognized in medicine, such as migraine and torticollis (neither of which [is] associated with lesions or cellular pathology) would fail to qualify.

 is defined in many different ways, depending on the needs, training, and expertise of the observer. For the pathologist, the term generally means something quite different than what it represents for the primary care physician, the epidemiologist, or the forensic psychiatrist. Yet one thing is clear: Physicians in general view disease in pragmatic and humanistic terms, applying the term to a very broad spectrum of human suffering and incapacity. One remarkably sweeping definition was provided in no less a source than the 8th edition of Harrison’s 

 (italics added for emphasis): “The clinical method has as its object the collection of accurate data concerning all the diseases to which human beings are subject; namely, 

 conditions that limit life in its powers, enjoyment, and duration.”

Just as we recognize trigeminal autonomic cephalalgias as instantiations of disease, so too must we recognize the most serious psychiatric conditions as disease states. And just as patients with TACs must be taken seriously, so too must those afflicted by psychiatric disease.

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and Editor in Chief emeritus of

1. Pies R. On myths and countermyths: more on Szaszian fallacies. 

2. Pies R. Thomas Szasz and the language of mental illness. In: Haldipur CV, Knoll JL, and Luft E vD, eds. 

. Oxford University Press; 2019: 155-168.

3. Wei DY, Yuan Ong JJ, Goadsby PJ. Cluster headache: epidemiology, pathophysiology, clinical features, and diagnosis. 

4. Nahas SJ. Cluster headache and other trigeminal autonomic cephalalgias. 

5. Zeller T. There has never been a better time to have a headache. 

. July 23, 2021. Accessed July 28, 2021. 

7. Clay HB, Sillivan S, Konradi C. Mitochondrial dysfunction and pathology in bipolar disorder and schizophrenia. 

8.Nakahara S, Matsumoto M, van Erp TGM. Hippocampal subregion abnormalities in schizophrenia: A systematic review of structural and physiological imaging studies. 

9. Kendell RE. The concept of disease and its implications for psychiatry. 

10. Kendell RE. The myth of mental illness. In: Schaler JA, ed. 

Szasz Under Fire: The Psychiatric Abolitionist Faces his Critics

11. Baldessarini RJ. Epidemiology of suicide: recent developments. 

12. Thornicroft G, Rose D, Kassam A. Discrimination in health care against people with mental illness. 

The Meaning of Mind: Language, Morality and Neuroscience

14. Benning TB. No such thing as mental illness? Critical reflections on the major ideas and legacy of Thomas Szasz. 

Harrison’s Principles of Internal Medicine

, 8th ed. G.W. Thorn et al, eds. McGraw-Hill; 1977.

 Responding to the criticisms of antipsychiatry. 

. August 19, 2018. Accessed August 3, 2021.

How is “disease” defined? A popular criticism of psychiatry gets debunked. 

Why Thomas Szasz Did Not Write The Myth of Migraine

“Brain activity can be understood, that is, has meaning, only to the extent that it is a representation of the state of the body, of the external world, or of a potential behavior. Just as it would be pointless to analyze a book by investigating the chemical composition of paper and ink, a reductionist analysis of brain activity, that is, taking it apart and analyzing its nucleic acids, enzymes, receptors, and ion channels, fails to explain what brain activity accomplishes. The neuroscience of meaning requires experiments that study brain activity as the body moves through the world or as people describe their experience.”

- Howard Fields, Setting the Stage for Pain: Allegorical Tales From Neuroscience

The English word pain is derived from the Latin word poena, meaning penalty or punishment. Because of the intrinsically intimate and subjective nature of pain, philosophers and medical providers struggle to find a definitive definition of the word. It is variable through references, authors, and times, with conceptualizations focusing alternately on the biomedical, emotional, or behavioral components of the phenomenon. The philosopher René Descartes’ mechanistic conceptualization of pain as a sensation, where the animal merely reacts to the noxious stimulus, dominated scientific and folk beliefs about pain into the mid-20th century.

 The more modern emergence of the concept of being-in-pain, which includes the subjectivity of the individual in the experience, opens the door for a bigger involvement of mental health professionals in pain management.

 International Association for the Study of Pain

 coined a new definition of pain in 1979: “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

 This flexible definition acknowledges the sensory, cognitive, affective, and motivational processes that influence the experience of pain and allows for a broader exploration of its subjectivity. It trades a purely neurological view for a more holistic conceptualization that considers the totality of the pain and, more importantly, of the patient.

The differentiation between acute and chronic pain has proven to be clinically useful for tailoring interventions. Traditionally, the distinction between acute and chronic pain has relied upon a single continuum of time, with the designation of an arbitrary interval as a transition point, most commonly between 3 and 6 months. Another way to characterize chronic pain is pain that extends beyond the expected period of healing—assuming one knows what that should be.

Both acute and chronic pain are major public health problems with high health care costs and resource requirements. According to a 

, the conservative estimate of the health care cost of pain is around $560 to $635 billion annually, which is significantly greater than that of heart disease, cancer, or even diabetes mellitus.

 Because of this high prevalence and significant morbidity, pain has earned the designation of “the fifth vital sign.”

Despite these tremendous expenses and heroic efforts (using sophisticated technology, biomedical advances, and ever-growing research), most pain conditions have no final options for a cure. The only potent analgesics available are opioids, which can be problematic given the current opioid epidemic in Western countries. However, with the broader and multifaceted understanding of pain, patient care has moved from a focus on eradicating pain, as based on objective pain scores, to improving the patient’s quality of life, while simultaneously decreasing pain to a level that is acceptable to the individual patient. To achieve this goal, the clinical integration of mental health providers in pain management teams has become more widespread.

The Relationship Between the Experience of Pain and Mental Health

If we agree with Ludwig Wittgenstein, PhD, who posited that “words are connected with the primitive, the natural expressions of the sensations and are used in their place,”

 it is not hard to see that even in the everyday language about pain, there exists a significant overlap between the purely physical experience of pain and the consequent subjective emotional aspects that arise with it. It might even seem that the connection transcends all elaborate philosophical theories and is deeply felt and expressed on an instinctual level. The most obvious example of the connection is that expressions like “broken-hearted” or “a slap in the face” are often used in multiple languages to describe experiences of physical as well as emotional, psychological, or even spiritual suffering.

This intimate and intricate relationship is also well understood even if one chooses to look at it from a purely neurobiological perspective. Although pain might initially originate from peripheral sensory receptors, the experience of pain is not complete without the 

modulatory involvement of the central nervous system

 Afferent stimuli from the thalamus, the limbic system, and cortical structures like the frontal lobe and the somatosensory cortex amplify or diminish the peripheral painful stimuli and add a subjective emotional component to the sensation. Functional imaging techniques and direct brain stimulation studies have demonstrated a striking overlap between central structures implicated in the 

 In addition, recent studies have described how chronic pain changes grey matter in the brain, resulting in secondary psychiatric symptoms and disorders. These studies thus emphasize a 

An individual’s experience of pain cannot be understood in a sterile context. With this conceptualization comes the possibility of applying psychological principles to the treatment of pain. Cognitive behavioral theories of pain are based on the premise that cognitions, emotions, behaviors, and physical sensations are all interrelated and exist within a particular context.

 Psychologists observe that changes in any of these areas can have wide-ranging influences through a circular effect on each other.

 illustrates how the different components of cognitive behavioral therapy (CBT) interact with each other to create vicious cycles, which in turn can cause a clinical increase in symptoms. From an interpersonal perspective, it is also clear that persistent personality traits can influence the subjective experience and expression of pain. Specific defensive and coping styles in an individual may create a particular and sometimes 

 Finally, although there is limited interest in the psychodynamic perspective of pain, multiple authors have argued that patients communicate on multiple conscious and unconscious levels through bodily manifestations, and that pain expressions hold 

 that warrant psychological and psychoanalytic exploration.

The Empirical Evidence for an Interdisciplinary Approach to Chronic Pain

From a more practical standpoint, evidence-based medicine shows a significant association between pain and mental health disorders and symptoms. There exists a statistically important comorbidity between acute and chronic pain and depressive disorders, anxiety disorders, substance use disorders, and personality disorders.

 Empirical evidence shows higher efficacy for the multidisciplinary and interdisciplinary management of pain that is based on the biopsychosocial model, which combines physical therapy, pain management by medication, patient education, ergonomic training, psychiatric treatment, and psychotherapy, among others. These interventions have shown significant results on the ratings of pain intensity scores, as well as on the quality-of-life measures that encompass both mental health and the functional impacts.

The Role of the Consultation-Liaison Psychiatrist in the Management of Pain

Consultation-liaison (C-L) psychiatrists are key members and leaders of interdisciplinary pain management teams. Psychiatry residents get the most 

 during the substance abuse/addictions (60%) and the C-L psychiatry (57%) rotations.

C-L psychiatrists are uniquely qualified to help patients with pain and play an important role in the pain management team. Although most primary care physicians and medical specialists can diagnose and initiate the treatment of psychiatric disorders, C-L subspecialists can diagnose more subtle and complex mood or anxiety disorders, substance use disorders, or personality disorders in a general medical setting. They can also participate in the pharmacological and even interventional management of pain, detect possible drug-drug interactions in these medically complex patients, and screen for possible medication side effects.

In addition, as the name of the specialty reveals, C-L psychiatrists are experts in bridging the gap between the patient and the other medical teams. They can relay messages in an empathic and understanding way and bring the goals of treatment into alignment with the patient’s values, preferences, and styles. Their integrated view of patients allows for reflection on behavioral, interpersonal, and psychodynamic formulations of the patient’s pain experience that can be communicated to the team to personalize the treatment and thus improve the quality of the care. 

 details the separate and overlapping roles of the pain specialist and the C-L psychiatrist.

Exploring the Future of C-L Psychiatry Within Pain Management Teams

 showed a national improvement of pain education in psychiatry training.

 The investigators found that more than two-thirds (70%) of program directors supported having psychiatry residents receive education and training in chronic pain management. This is a significant improvement from the less than 50% found in the 

The increase in pain management education is not limited to psychiatry residency; it also currently includes more continuing medical education (CME) focused on psychiatric aspects of pain, medication management of pain, meditation, CBT, and other strategies.

 This is particularly true for C-L psychiatrists, whose national professional organization, the 

Academy of Consultation-Liaison Psychiatry

, specifically includes CME for chronic pain as well as special interest groups for palliative medicine, addiction and toxicology, and collaborative and integrated care, among others.

Overall, the future of this integrated approach to pain with the inclusion of C-L psychiatrists looks bright. Encouraging systemic changes are starting to occur, including changes to reimbursement for medical services (meaning procedural and nonprocedural pain interventions will be more equally compensated). They also include changes to the referral processes between specialists, making the processes more efficient and allowing the emergence of bigger interdisciplinary teams.

We believe that an integrated treatment actively involves C-L psychiatry which, in the words of 

, constitutes the final missing P in the management of pain,

 and which can significantly improve health outcomes and the quality of life of this patient population.

is a consultation-liaison psychiatrist and palliative care fellow at MedStar Washington Hospital Center in Washington, DC.

is clinical and deputy scientific director of the National Institute of Mental Health and the National Institutes of Health, and acting clinical director of the National Center for Complementary and Integrative Health, all in Bethesda, MD.

Meditations on First Philosophy: With Selections From the Objections and Replies

. Moriarty M, trans. Oxford University Press; 2008.

The International Association for the Study of Pain definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes

3. Mehta A, Chan LS. Understanding of the concept of “total pain”: a prerequisite for pain control. 

The economic costs of pain in the United States

. Anscombe GEM, trans. Wiley-Blackwell, 1997.

Pain and suicidality: insights from reward and addiction neuroscience

A common neurobiology for pain and pleasure

Chronic pain may change the structure of the brain

New evidence for a pain personality? a critical review of the last 120 years of pain and personality

Parallel pains and dynamic dilemmas: psychodynamic considerations in approaching and managing chronic physical pain

Epidemiology of pain and relation to psychiatric disorders

Prog Neuropsychopharmacol Biol Psychiatry

13. Ilgen MA, Kleinberg F, Ignacio RV, et al. 

Noncancer pain conditions and risk of suicide

14. Scascighini L, Toma V, Dober-Spielmann S, Sprott H. 

Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes

15. Gerdle B, Åkerblom S, Brodda Jansen G, et al. 

Who benefits from multimodal rehabilitation - an exploration of pain, psychological distress, and life impacts in over 35,000 chronic pain patients identified in the Swedish Quality Registry for Pain Rehabilitation

The status of pain medicine education in psychiatry: a survey of residency training program directors

17. Majeed MH, Ali AA, Metzger S, Sudak DM. 

Pain management education and training during psychiatry residency: a report on national progress

18. Balon R, Morreale MK, Coverdale JH, et al. 

The role of psychiatric education in pain management

19. Academy of Consulation-Liaison Psychiatry. CLP 2020: delivering our vision of integrated care. 2020. Accessed March 22, 2021. 

The missing p in psychiatric training: why it is important to teach pain to psychiatrists

With a broader and multifaceted understanding of pain, patient care can move from a focus on eradicating pain, as based on objective pain scores, to improving the patient’s quality of life, while simultaneously decreasing pain to a level that is acceptable to the individual patient.

The Final “P” in Pain Management

Pride is often what drives people to their successes in life. The feeling is associated with a job well done and has been considered an important part of preventing burnout, especially in difficult situations. Since March 2020, headlines around the world have conveyed the sense of pride frontline health care workers, although tired and weary, have felt as they tackled 

. It helped motivate them day in and day out, despite the challenges, to bravely help so many who were affected by the virus.

Psychiatrists, too, have much to be proud about. The field was among the first to 

 visits, ensuring the mental and physical well-being their patients. Similarly, clinicians shed light on the need for interactions to combat loneliness associated with quarantining as well as the importance of self-care for all health care professionals, as evidenced by many articles on our website and in the pages of 

In addition, psychiatry is stepping in to address the chronic pain epidemic. Almost half of the adult US population experienced pain on some days, and about one-fifth had pain most days or every day, 

 by the Centers for Disease Control and Prevention. The number is staggering, and research indicates pain has played a role in the country’s devastating opioid epidemic.

 has addressed pain to keep readers up to date. In this issue, Paul Noufi, MD, and Maryland Pao, MD, further explore the role of consultation-liaison psychiatry and how it can be used to benefit patients who have pain. With this important integrative approach, the authors conclude that, overall, the future looks bright.

Also within these pages, John J. Miller, MD, delves into a discussion on 

. In his monthly editorial, Miller lays the foundation and history of the field and how it affects psychiatry. From there, Harold J. Bursztajn, MD, and colleagues explore the role of epigenetics in resilience and examine the transgenerational transmission of resilience following trauma in this month’s continuing education article. Psychiatry can take pride in these efforts to leverage genetics and epigenetics as a means to prevent and treat psychiatric disorders.

June is also LGBTQ Pride Month, which commemorates the 

 in Manhattan, New York. Along with celebrations, the month presents an opportunity to address the wider social implications. 

 features the second part of our Special Report on sexual and gender minorities (SGM). The collection wraps up this month with an important discussion on the mental health implications of fertility options and trauma-focused cognitive-behavioral therapy for SGM youth.

Much more can be found in this issue, including thought-provoking commentaries and clinical insights from new and regular contributors. We hope you find these articles interesting, entertaining, and informative. As always, we take pride in providing the top-quality information you need to support you, your practice, and your patients. ❒

Pride: A Driving Force

Most health care professionals are aware that medical care in this country varies a great deal based on the patients’ race and ethnicity. We only have to look at the current coronavirus disease 2019 (COVID-19) crisis, in which Black individuals have been 

 both in number of infections and deaths as a result of a myriad of psychosocial, genetic, and environmental factors.

On top of unequal access, some individuals hold discriminatory beliefs about pain experienced by individuals of different racial and ethnic groups. In 1892, S. Weir Mitchell, MD, the father of American neurology, wrote about the experience of pain in White people of Northern European ancestry in comparison with Black and Native American people. He stated, “In our process of being civilized, we have won, I suspect, intensified capacity to suffer. The savage does not feel pain as we do.”

This view of pain was often used to rationalize the mistreatment of enslaved and Native American people: when violence was inflicted on them, they did not suffer as White people did. Pre-Civil War, 19th century New Orleans physician Samuel A. Cartwright, MD, said he identified “dysaesthesia Aethiopis,” an inherited disorder specific to Black individuals that made them insensitive to pain.

These views were perpetuated solely based on racism, without any science to support them. However, we now know that genetics can play a significant role in disease. Different races and ethnicities can be more at risk for certain diseases, such as sickle cell disease among Black people and Tay-Sachs disease among people of Ashkenazi Jewish ancestry. Thus, there is still the question of whether pain is experienced differently by individuals from different backgrounds.

Pain as a cultural construct considers conscious and unconscious biases, as well as methods for assessing and managing pain in all patient populations, including those with mental health challenges.

Pain

Pain on the Brain: The Relationship Between Bad Dreams and Chronic Pain

Nasal Spray for Treatment of Migraine Approved by FDA

Why Thomas Szasz Did Not Write The Myth of Migraine

The Final “P” in Pain Management

Pride: A Driving Force

Race, Ethnicity, and Chronic Pain

Pain and Smoking: Is There an Association?

Exploring the Relationship Between Posttraumatic Stress and Chronic Pain

Psychiatry’s Role in the Management of Chronic Pain

Sleep Disturbances as a Sequalae of Chronic Pain