Taming Artificial Intelligence in Psychiatry and Pain Medicine

Today, deep learning (DL) algorithms are intertwined with our daily life. This subdomain of artificial intelligence (AI) technology is used to unlock your phone by only detecting your face, find the best path from work to your home or vice versa, or detect anomalies in the human cells taken for lab tests. Yet, although AI technology is helping in many fields, whether it has done so in the medical field is debatable. DL lacks reasoning; it is unable to determine the causes of events. This is especially crucial when it comes to the health care sector. At this point, computers cannot help physicians with their duties. On the contrary, they are the cause of burnout in more than half of physicians in United States. One of the causes of burnout repeatedly pointed out by physicians is the digitalization of medicine. This chapter presents some of the AI approaches that could help physicians. It also discusses the current limitations and dangers inherent to many of today’s state-of-the-art AI systems. The authors provide some ideas about the future of AI in pain medicine and psychiatry.

Detecting and Managing the Untreated Pain in Dementia

Dementia affects more than 30 million people worldwide and is a major public health issue because of the complex treatment and care needs of these older patients. Pain is very common in people with dementia and is closely linked to key clinical outcomes, including mobility and falls, behavioral symptoms, mental health, and quality of life. Effective pain management is therefore essential to provide a good quality of care for these individuals. Pain assessment and treatment can be challenging in dementia because of loss of communication and insight as the condition progresses. There are also indications that the dementia syndrome itself affects the experience of pain and response to established treatment approaches. Guiding principles for pain management are therefore focused on a person-centered approach, with careful monitoring to avoid the risk for polypharmacy and treatment sensitivity that is common in people with dementia. This chapter outlines the current evidence pertaining to pain in people with dementia and sets out recommendations for both assessment and treatment of pain in this patient group.

Pain and Comorbid Psychiatric Illnesses in Elderly People

Chronic pain is often associated with anxiety, depression, and frailty. The relationship between pain and mental illness is complex and bidirectional. In elderly people, poor self-rated health is strongly associated with pain severity, and pain-related interference with daily activities leads to depression. There is a shared neural substrate within the central nervous system (CNS) between pain and depression, which have a common neuroanatomical organization within the CNS. The close association between pain and depression means that assessment of pain should be accompanied by assessment of depression even if by the single question, “Are you depressed?” The physiological changes in aging influence the pain experience and analgesic tolerance, which diminishes in the presence of comorbidities. Tolerance to antidepressants is also diminished, with a greater risk for drug–drug interactions due to polypharmacy, which accompanies older age.

Catastrophizing in Comorbid Chronic Pain and Mental Illness

Catastrophizing, or the tendency to emphasize and exaggerate the occurrence of negative consequences in a specific situation, has been shown to play an important role in the development and maintenance of chronic pain. Dynamically viewed as a contributor, mediator, and result of chronic pain suffering, catastrophizing has notable importance for clinicians treating patients’ comorbid chronic pain and mental illness. Exciting research on catastrophizing and neuroplasticity in persons with chronic pain promises to expand our understanding of pain catastrophizing, pain chronification, and cortical structural neuroplasticity in response to psychological interventions. This chapter provides a selective review of the assessment and neural correlates of pain catastrophizing as well as the role of catastrophizing as a prognostic factor for pain-related outcomes. The interactions between catastrophizing and chronic pain are also explored in the context of key comorbid mental conditions: depression and insomnia. Clinical implications for the practicing clinician are discussed.

Post-traumatic Stress Disorder and Chronic Pain in the Military

This chapter summarizes the current literature on post-traumatic stress disorder (PTSD) and chronic pain among military personnel in Canada, the United States, and the United Kingdom, including an overview of clinical features, prevalence, correlates, comorbidity, assessment, and intervention. PTSD and chronic pain are both prevalent among military populations and commonly co-occur; however, prevalence estimates tend to vary in the literature, according to type of assessment, timing of assessment, and subsample of interest. Both PTSD and chronic pain are independently associated with various adverse correlates such as psychiatric and physical health comorbidity, and research suggests there are poorer health and adverse psychosocial effects when these conditions co-occur. These findings highlight the importance of adequate prevention, screening, and interventions among this population.

Considering Depression and Anxiety as Risk Factors for Temporomandibular Joint Disorder

Temporomandibular joint disorder (TMD) is a painful functional disorder of the temporomandibular joint, masticatory muscles, and associated musculoskeletal structures of the head and neck. TMD is a type of chronic pain and is widely used as a model for chronic pain. The etiology of TMD pain is multifactorial. Biological, behavioral, environmental, social, emotional, and cognitive factors can contribute to TMD. TMD can manifest with musculoskeletal facial pain complaints and with different forms of jaw dysfunction. Biobehavioral studies suggest an association between TMD pain and coexisting psychopathology, including depression and anxiety. This chapter presents practical clinical recommendations on how to treat patients with symptoms of depression, anxiety, and TMD pain. The authors underline the importance of considering depression and anxiety as risk factors for TMD.

Neuroimaging Correlates for Psychological and Chronic Pain Experiences

Psychological factors play a key role in the pain experience. Clinical and experimental research has highlighted altered behavioral, cognitive, and emotional responses as endemic in chronic pain populations, which contribute to physical dysfunction and to depression, anxiety, and other psychiatric disorders. Neuroimaging research has complemented the knowledge in this domain by identifying how neural structure and function are altered in chronic pain. Brain processes related to mental illness, emotion, memory, and cognition are distributed throughout the brain and modulate pain processing in both the acute and chronic states. These processes can be targeted both behaviorally and neurophysiologically through noninvasive and nonpharmacological psychological therapies, including cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based stress reduction. Psychological therapies are further supported by emerging neuroimaging research that demonstrates changes in brain structure and function associated with positive changes in patients’ responses to pain and overall improved quality of life.

Glial Cells and Pro-inflammatory Cytokines as Shared Neurobiological Bases for Chronic Pain and Psychiatric Disorders

This chapter reviews the roles of cytokines and glial cells in chronic pain and in psychiatric disorders, especially depression. One important role of cytokines is in communicating between activated glia and neurons, at all levels of the nervous system. This process of neuroinflammation plays important roles in pain and depression. Cytokines may also directly regulate neuronal excitability. Many cytokines have been implicated in both pain and psychiatric disorders, including interleukin-1β‎ (IL-1β‎), tumor necrosis factor-α‎, and IL-6. More generally, an imbalance between type 1, pro-inflammatory cytokines and type 2, anti-inflammatory cytokines has been implicated in both pain and psychiatric disorders. Activation of the sympathetic nervous system can contribute to both pain and psychiatric disorders, in part through its actions on inflammation and the cytokine profile.

Recognizing the Co-occurrence of Chronic Pain and Mental Illness

Epidemiological data regarding chronic pain and psychiatric disorders are reviewed. Particular attention is given to the interplay between pain and depressive and anxiety disorders. In the general population, 19 to 33% of responders report chronic pain, with higher rates in elderly people. Major depression is one of the most common medical problems, affecting nearly 6% of the population, with a lifetime prevalence of 11 to 14%. The presence of depression in persons with chronic pain is significantly higher (21%) than that in the general population, and this proportion is even higher (52–85%) in specific populations of patients attending specialist clinics. Conversely, convincing evidence published in numerous studies has documented that at least 50% of depressed patients report painful symptoms. Pain exerts a negative effect on treatment and a poorer outcome in multiple domains of quality of life. Moreover, pain increases the economic burden resulting from depression. A close relationship between pain and depression has been established in the functional somatic syndromes of fibromyalgia and irritable bowel syndrome. An association between anxiety disorders and pain has also been documented. Epidemiological studies have provided evidence suggesting the common co-occurrence of pain and selected psychiatric disorders. This is an indication for practitioners to examine patients with pain for symptoms of depression and anxiety disorders and conversely to interview patients with psychiatric disorders in regard to the presence or absence of pain. These studies also provide the inspiration for further investigations of the intriguing shared biological basis or pain and psychiatric disorders.

Innovative Management of Chronic Pain and Psychiatric Comorbidities

Chronic debilitating pain causes physical, emotional, cognitive, and spiritual suffering. Chronic pain is frequently associated with psychiatric comorbidities, such as affective and anxiety disorders, further enhancing the suffering and functional disability of patients with pain. For much of the past three decades, treatment for pain has focused on the physical aspect of pain with little attention to emotional, cognitive, and spiritual maladies. We aim to describe comprehensive rehabilitation programs that take into consideration the entire patient. While the concept is not novel, comprehensive programs became nearly extinct for many years because of a variety of factors. Possibly the most innovative concept in pain medicine is the re-emergence of these programs, along with a variety of newer treatment modalities.