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January 3, 2011

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

Author Affiliations

Author Affiliations: Clinical Psychopathology Laboratory, McLean Hospital (Dr Elman), and PAIN Group, Department of Psychiatry, McLean Hospital and Massachusetts General Hospital (Dr Borsook), Harvard Medical School, Boston, Massachusetts; and Departments of Psychiatry and Radiology and Molecular and Behavioral Neuroscience Institute, University of Michigan, Ann Arbor (Dr Zubieta).

Arch Gen Psychiatry. 2011;68(1):12-20. doi:10.1001/archgenpsychiatry.2010.174

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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