Elsevier

Progress in Neurobiology

Volume 109, October 2013, Pages 1-27
Progress in Neurobiology

Pain and suicidality: Insights from reward and addiction neuroscience

https://doi.org/10.1016/j.pneurobio.2013.06.003Get rights and content

Highlights

  • Suicidality is exceedingly prevalent in pain patients.

  • Emotional and physical pains are mediated by overlapping neural systems.

  • Social losses are linked to emotional pain and suicidality.

  • Suicidal behavior is ingrained in pain neuropathology.

  • Addiction neuroscience informs neurobiology of pain, suicidality and attachment.

Abstract

Suicidality is exceedingly prevalent in pain patients. Although the pathophysiology of this link remains unclear, it may be potentially related to the partial congruence of physical and emotional pain systems. The latter system's role in suicide is also conspicuous during setbacks and losses sustained in the context of social attachments. Here we propose a model based on the neural pathways mediating reward and anti-reward (i.e., allostatic adjustment to recurrent activation of the reward circuitry); both are relevant etiologic factors in pain, suicide and social attachments. A comprehensive literature search on neurobiology of pain and suicidality was performed. The collected articles were critically reviewed and relevant data were extracted and summarized within four key areas: (1) physical and emotional pain, (2) emotional pain and social attachments, (3) pain- and suicide-related alterations of the reward and anti-reward circuits as compared to addiction, which is the premier probe for dysfunction of these circuits and (4) mechanistically informed treatments of co-occurring pain and suicidality. Pain-, stress- and analgesic drugs-induced opponent and proponent states of the mesolimbic dopaminergic pathways may render reward and anti-reward systems vulnerable to sensitization, cross-sensitization and aberrant learning of contents and contexts associated with suicidal acts and behaviors. These findings suggest that pain patients exhibit alterations in the brain circuits mediating reward (depressed function) and anti-reward (sensitized function) that may affect their proclivity for suicide and support pain and suicidality classification among other “reward deficiency syndromes” and a new proposal for “enhanced anti-reward syndromes”. We suggest that interventions aimed at restoring the balance between the reward and anti-reward networks in patients with chronic pain may help decreasing their suicide risk.

Section snippets

Neurobiology of pain

Illness is the doctor to whom we pay most heed; to kindness, to knowledge, we make promise only; pain we obey.

Marcel Proust. Remembrance of Things Past (1922)

The neurobiology of pain has been reviewed in detail elsewhere (Costigan et al., 2009, von Hehn et al., 2012) and some elements are briefly presented here. Acute painful sensation signals real or perceived tissue damage from environmental hazards. Chronic pain usually arises from neuropathic (damage to the peripheral or central nervous

The opponent process

There is no love which is not pain

There is no love which does not bruise

There is no love which does not wither

Louis Aragon. There is no happy love (1946)

A great truth is a truth whose opposite is also a truth.

Thomas Mann. Essay on Freud (1929)

The valence-based approach/avoidance dichotomy does not seem to be universal, however, as some painful (Nixon et al., 2008) and/or aversive (Sapolsky, 1998, Selye, 1976) stimuli may be perceived as desirable (i.e., rewarding and reinforcing) across various

Therapeutic considerations

But he who is joined with all the living has hope, for a living dog is better than a dead lion. For the living know that they will die, but the dead know nothing, and they have no more reward, for the memory of them is forgotten. Their love and their hate and their envy have already perished, and forever they have no more share in all that is done under the sun.

Ecclesiastes. The English Standard Version Bible (1971)

Suicide- and pain neuropsychopathologies are indisputably enormous entities with

Summary and conclusions

Any knowledge that doesn’t lead to new questions quickly dies out: it fails to maintain the temperature required for sustaining life.

Wislawa Szymborska. Nobel Lecture (1996)

Suicide is a question occupying human mind since the dawn of history and its ethical, philosophical, logical or even clinical legitimacy is certainly far from been addressed by the present paper. A compilation of balanced views on this conundrum is presented in the middle column of Table 4.

Pain patients are vulnerable for

Acknowledgments

The authors gratefully acknowledge Ms. Adriana Johnson for her help with the preparation of the manuscript and support from the Mayday Fund/Herlands Fund for Pain Systems Neuroscience Research (DB).

This study was supported with resources and the use of facilities at the Providence VA Medical Center. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.

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    The authors equally contributed to this work.

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