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“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

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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.

A complicating factor in this discussion is how the experience of pain is affected by culture. It is readily apparent that it is more acceptable in some cultures and societies, often based on race or ethnicity, to complain about pain. How much of this is due to actual differences in the pain experience versus cultural acceptability of reporting pain—nature versus nurture—remains unclear.

 the effects of race and ethnicity on the care individuals received for chronic pain.

 The review identified trends in the effects of race and ethnicity on the experience of pain and how it is treated. Among the multitude of previous studies, one can find many different results, ranging from race and ethnicity playing significant roles to playing virtually no role.

Some studies have reported that Black individuals and people who belong to certain ethnic minority groups have higher pain thresholds, while other studies have 

 Minority patients, especially those from groups in which there are relatively small numbers of represented physicians, may have their level of pain underestimated by their caregivers.

Several studies have examined affects of race or ethnicity on the prescribing of opioids for pain. The most common finding was that Black patients were less likely to be prescribed opioids than White patients; however, it is worth noting that 

 patients were less likely to receive opioids than non-Hispanic White or non-Hispanic Black patients.

 Furthermore, some studies found that Black patients who were prescribed opioids were monitored more closely for misuse than White patients.

In light of the prescription epidemic in this country, resulting in rising rates of misuse and overdoses, it could be argued that more restrictive prescribing and closer monitoring might be a positive thing. If so, Black patients might accidentally benefit from these prescribing patterns. However, there is no indication that physicians are more carefully looking out for their Black patients than for their White patients. Even if the result is positive, there is no apparent intent. Furthermore, research has shown that Black patients and non-White Hispanic patients may have a more difficult time than White patients filling opioid prescriptions, as pharmacies in their neighborhoods may carry 

Unfortunately, there has been a tendency to have limited participation of non-English speakers and immigrants in studies of 

, and this may have resulted in an unrepresentative sample. Considering that pain is a subjective complaint that must be self-reported, limited language skills could impair patients’ ability to convey the presence and severity of pain, all important factors in determining proper treatment protocols.

The extent to which race, socioeconomic status, and 

 contribute to the apparent discrepancies in the management of pain remains unclear. The issue of poor access to health care may extend beyond just the pain itself and may also affect the identification and treatment of underlying disorders that may be causing or exacerbating the pain. This includes mental health issues, most notably depressive and anxiety disorders, which can play important roles in the development and maintenance of 

It is not too surprising that so many factors may explain variances in pain among different racial and ethnic groups. We know that there are many elements involved in the development of pain, especially chronic pain, including genetic, cultural, psychological, and environmental influences. The importance of each factor can vary from individual to individual.

The authors of the current study noted that there are no easy answers to pain management discrepancies, especially between Black and White individuals in the United States. More research is needed to identify the reasons for these discrepancies and the best methods for addressing them. Physicians should be aware of biases, including unconscious ones, and the methods for assessing and managing pain, especially among patients who may belong to different racial and ethnic groups than they do. Viewing all patients as complex individuals whose pain may involve many factors is crucial.

is in private practice in Philadelphia, Pennsylvania.

2. Cartwright SA. Report on the diseases and physical peculiarities of the negro race. In: Caplan AL, McCartney JJ, Sisti DA, eds. 

Health, Disease, and Illness: Concepts in Medicine

Racial and ethnic disparities in the treatment of chronic pain

4. Green CR, Hart-Johnson T. The impact of chronic pain on the health of black and white men. 

5. Hausmann LRM, Gao S, Lee ES, Kwoh KC. Racial disparities in the monitoring of patients on chronic opioid therapy. 

6. Nguyen M, Ugarte C, Fuller I, Haas G, Portenoy RK. 

Access to care for chronic pain: racial and ethnic differences

7. Bauer SR, Hitchner L, Harrison H, Gerstenberger J, Steiger S. 

Predictors of higher-risk chronic opioid prescriptions in an academic primary care setting

8. Hollingshead NA, Vrany EA, Stewart JC, Hirsh AT. 

Differences in Mexican Americans’ prevalence of chronic pain and co-occurring analgesic medication and substance use relative to non-Hispanic white and black Americans: Results from NHANES 1999-2004

9. Becker WC, Starrels JL, Heo M, Li X, Weiner MG, Turner BJ. Racial differences in primary care opioid risk reduction strategies. 

10. Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. “

We don’t carry that”--failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics

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.

Race, Ethnicity, and Chronic Pain

The association between smoking cigarettes and the risk of developing serious and potentially fatal health problems (most notably cardiovascular diseases, pulmonary diseases, and cancer), has long been accepted fact. However, an additional health problem that may also be associated with smoking has often been overlooked: pain.

Two recent papers indicate a strong association between smoking and pain.

 Among the review’s important findings is that those who suffer from chronic pain are substantially more likely to smoke than are those who do not suffer from chronic pain. Although smoking rates continue to decline in the latter group, this does not appear to be occurring in those with pain.

Cigarette smoking has been cited as a risk factor for a wide variety of painful conditions, including back pain, 

, and diabetic peripheral neuropathy. Smoking appears to be associated with both the development and severity of pain.

The second paper specifically studied the most likely locations of pain among individuals who smoke. The 

 examined data from a 2003 to 2004 National Health and Nutrition Examination Survey, which contained data from comprehensive bodily pain questionnaires in addition to questions on other health issues, including tobacco use.

 The study compared 1054 participants who smoked tobacco with 1316 participants who did not.

Those who smoked were found to be more likely to suffer chronic pain. Although the likelihood of pain was increased throughout the body, the study found that spine pain, and especially low back pain, had the strongest association with smoking. The second strongest association was between 

 and smoking. Smoking was also associated with both trunk pain, which included the chest and abdomen, and limb pain. (All statistical associations were drawn from Smuck et al.

This is an interesting and perhaps an unexpected finding. Because of the association between smoking and cardiovascular and cerebrovascular problems, it is easy to see why headaches would be fairly common among individuals who smoke. However, it might be reasonably expected that pain in the trunk and 

 would be more common than pain in the spine. The authors suggest that vascular factors may play a greater role in back pain than is often thought.

, which are becoming more popular, are any less associated with pain than traditional cigarettes remains an unanswered question.

From personal experience treating patients with chronic pain who also smoke, I know that helping them with smoking cessation attempts can be challenging. Although most patients are often well aware of the risks associated with smoking, their pain and its impact on their lives may make it more difficult for them to quit. Their pain may make them feel restricted, and their ability to participate in previously enjoyable activities is limited. Smoking is among the few such activities in which they can still indulge. They may also feel that smoking helps them cope with the pain.

 may have some analgesic effects, but abstaining from smoking may 

 individuals to suffer hyperalgesia, a lowering of the pain threshold.

 Thus, those who smoke may receive temporary relief from tobacco use, and their pain may get worse when they try to stop.

Additionally, depression and anxiety are frequent 

 among those with chronic pain, and their presence can also contribute to the challenge of getting patients to stop smoking.

Ultimately, all evidence points to the importance of convincing patients with chronic pain who also smoke that tobacco is not helpful. Indeed, tobacco may be significantly exacerbating their pain and adding to their misery.

The multitude of challenges can understandably make it difficult to persuade patients with chronic pain to stop using tobacco. Unfortunately, only a 

 of studies have sought to investigate the best treatments for attaining this goal.

Although no single optimal treatment has yet been identified, it appears that while nicotine replacement therapy can be useful, the 

 that are most successful are those that address both the pain and the smoking using psychotherapeutic interventions.

 In this way, treating tobacco use disorder and comorbid chronic pain is similar to the treatment of pain and iatrogenic opioid use disorder, where both problems must be managed together to be successful in treating either.

Of course, this raises the important issue of who treats pain and how it is treated. (For more information on psychiatry and pain, see 

Psychiatric TimesTM November 2020 Special Report

For the most part, the management of chronic pain has been under the aegis of anesthesiology, followed by physiatry and neurology, with psychiatry far down the list. However, the order of these specialties would be reversed if we asked which is best able to aid in smoking cessation. One doubts that there are many anesthesiologists, physiatrists, or neurologists who have expertise in treating patients with nicotine addiction.

As a result, it is difficult for patients with chronic pain who smoke to find health care professionals qualified to treat both issues. If it appears to patients that smoking and pain are 2 separate problems that require different medical specialties to treat them, it may make it more difficult to convince them that the issues are actually entangled. Nonetheless, the evidence suggests that managing 1 issue may aid in managing the other.

This article was posted ahead of print on November 11, 2020, and has since been updated. -Ed

Pain, nicotine, and tobacco smoking: current state of the science

2. Smuck M, Schneider BJ, Ehsanian R, et al. 

Smoking is associated with pain in all body regions, with greatest influence on spinal pain

Nicotine deprivation increases pain intensity, neurogenic inflammation, and mechanical hyperalgesia among daily tobacco smokers

Nicotine withdrawal and stress-induced changes in pain sensitivity: a cross-sectional investigation between abstinent smokers and nonsmokers

Anxiety and depression in bidirectional relations between pain and smoking: implications for smoking cessation

A reciprocal model of pain and substance use: transdiagnostic considerations, clinical implications, and future directions

7. Hooten WM, LaRowe LR, Ditre JW, et al. 

Effects of a brief pain and smoking cessation intervention in adults with chronic pain: a randomized controlled trial

Two recent papers look at the subtle and surprising links between smoking and pain in different parts of the body. 

Pain and Smoking: Is There an Association?

Chronic pain is a massive and costly health problem

 and among the main non-fatal causes of years lived with disability worldwide.

 In the United States alone, an estimated 50 million adults are suffering from chronic pain.

 Huge efforts have been made in past decades to better understand, prevent, and treat chronic pain. A common link between chronic pain and posttraumatic stress disorder (PTSD) has emerged as a result of this research. Many individuals with chronic pain suffer from PTSD due to the incidents that caused trauma-related distress, but chronic pain is also commonly found in individuals with PTSD as their primary disorder. Hence, a better understanding of this comorbidity may be important for the treatment of both disorders.

 vary notably due to differences in sampling and assessment tools. Of importance for the interpretation of prevalence rates, many studies rely on fulfillment of diagnostic criteria based on PTSD screening questionnaires. Two recent systematic reviews reported mean-possible PTSD prevalence rates of 11.7% to 19.1% in clinical pain populations, also noting large subgroup differences.

 Similarly, chronic pain complaints are common in patients with a primary diagnosis of PTSD, with prevalence rates estimated to be as high as 80%.

In a recent systematic review of studies on refugees with PTSD, chronic pain complaints were very common. In some studies, almost all participants reported such complaints.

 Furthermore, several studies have found that higher levels of PTSD symptomatology in patients with chronic pain are associated with higher levels of 

, raising the possibility that the conditions not merely coexist, but may influence one another negatively.

Several theoretical possibilities have been put forward to explain the comorbidity of PTSD and pain. These have mainly focused on shared, predisposing vulnerabilities, or on how the conditions may affect one another.

Asmundson et al suggest that underlying predisposing factors or traits cause the development of both PTSD and chronic pain.

 sensitivity (the tendency to respond with fear due to the assumption that [anxiety] symptoms are harmful), may amplify the intensity of the initial emotional response to a traumatic event, thereby increasing the risk of developing either condition.

 Also, other biological and psychological vulnerabilities have been suggested, such as a lowered physiological threshold for alarm responses and feelings of loss of control and unpredictability.

 Vulnerabilities, together with the circumstances of the traumatic event, affect the emotional responses in the encounter and initiate cascades of cognitive bias, hypervigilance, avoidance behavior, autonomic responses, and muscular responsivity.

 A number of vulnerabilities and processes, then, may make an individual more prone to develop the comorbidity following trauma.

Maybe the most-cited model in the field is the Mutual Maintenance Model.

 This model suggests that chronic pain and PTSD maintain and exacerbate one another through 7 mechanisms. Attentional and reasoning biases toward potentially threatening stimuli as well as catastrophizing are suggested to lead to heightened expectations, overestimations, and selective and negative interpretations of both pain-evoking and fear-evoking stimuli. Furthermore, pain may serve as a traumatic cue, evoking fear and PTSD intrusion and hyperarousal, and vice versa. Avoidant coping styles, depressive symptoms, and fatigue are also potentially intertwined and could lead to physical deconditioning, inactivity, disability—all preventing fear extinction. PTSD-related anxiety may also include pain perception directly. Finally, cognitive overload characterizes both conditions, and it leads to limited capacity to employ adaptive coping strategies.

 developed the Perpetual Avoidance Model, which suggests that PTSD symptomatology begins early post-trauma. Here, dysfunctional cognitions, intrusive symptoms, hyperarousal, avoidance behavior, and inactivity all fuel one another in a circular process. The model posits that pain may be initiated or increased as a function of hyperarousal, leading to reinforced fear-avoidance behavior and inactivity. In addition, Jenewein and colleagues argued that fear-learning deficits and impaired capacity to inhibit fear in PTSD may contribute to increased pain perception, pain sensitivity, and fear responses to painful stimuli.

 This idea builds on classical fear conditioning theory, in which fear-learning deficits cause an over-association of pain cues and prevent adaptive safety learning. Incorrect interpretations of bodily symptoms can lead to reinforcement and catastrophizing.

 As a final note, pain issues can also arise due to anxiety-related tensions.

 on pain sensitization, experimental studies find both increased and decreased pain perception, as well as unaltered pain perception.

 While these mechanisms are not fully understood yet, evidence shows that different pain profiles may be related to different PTSD symptoms and coping mechanisms. In a recent review

, PTSD hyperarousal has been associated with increased pain perception and dissociation with decreased pain perception. Also, the nature of the traumatic event may play a role in how PTSD affects pain sensitization. Combat-related PTSD was found to be associated with increased pain thresholds (the level at which a stimulus is experienced as pain), whereas accident-related PTSD was associated with decreased pain thresholds.

Different coping mechanisms may be related to dissociation and derealization. Whereas dissociation can lead to a reduction of conscious attention toward bodily sensations and incoming stimuli such as pain, anxiety and fearful appraisals may lead to attentional bias toward painful stimuli and thereby a decreased pain threshold. Hence, it seems that accident-related trauma is linked to an anxious and sensitizing reaction, whereas combat-related trauma may lead to a dissociative and habituative reaction. While differences in pain processing can be identified in experimental studies, subjective pain reporting most often points in the direction of a more severe symptom profile in relation to pain, disability, and distress when comorbid PTSD and pain persist.

The biological mechanisms behind pain sensitization and the development of chronic pain are complex but include regulatory mechanisms in the hypothalamic-pituitary-adrenal axis, inflammatory processes, immune system suppression, and fatigue.

Also, more complex interpersonal traumas such as physical and emotional abuse associated with war or sexual assault, for example, are of such a pervasive nature that the ability to trust others can be severely damaged, resulting in attachment insecurities that further increase the risk of developing long-term pain problems.

The high co-occurrence of chronic pain and PTSD and their possible entanglement underline the importance of conducting assessment for both PTSD and pain. Unfortunately, symptom overlap between pain and PTSD makes assessment a challenging task. In particular, symptoms related to the DSM-5 PTSD criterion D and criterion E (

) are also very common in individuals who have chronic pain but do nothave PTSD.

 contains items from the PTSD Checklist for DSM-5 (PCL-5) that are prone to misinterpretation. This exemplifies why screening can be a challenge, as individuals who misinterpret these items will sometimes unintentionally inflate their PTSD symptom scores. The key is to distinguish between the patients who feel upset about the consequences of traumatic pain and those who feel highly upset when thinking about the traumatic event itself. For example, negative beliefs about oneself (line 1) are often tied to a guilty conscience about being unable to fulfill one’s obligations due to pain. Loss of interest in activities and feeling cut off from individuals (lines 2 and 3) are often related to no longer being able to participate in sports and hobbies due to pain. Also, almost everyone with chronic pain at times feels irritable and has difficulty concentrating (lines 4 and 5). Similarly, chronic pain causes sleep problems (line 6). The problem is that intrusion symptoms like “feeling very upset when something reminded you of the stressful experience” (which are understood as unique PTSD symptomatology) are sometimes interpreted by patients as being upset when thinking about how pain hinders participating in activities, and not so much as being upset when thinking about the traumatic event itself.

The high co-occurrence of chronic pain and PTSD and their possible entanglement underline the importance of conducting assessment for both conditions. 

Pain

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

Addressing Pain in Patients With Bipolar Disorder

10 Salient Points About Migraine and Psychiatric Comorbidity

10 Factors Leading to Pain Complaints in the Absence of a Medical Diagnosis