Why The Pain Collective Integrated Psychiatry Early

At The Pain Collective, psychiatry is not an add-on in chronic pain care. It has been built into the clinical model from the start, because the evidence has long shown that persistent pain is a neurobiological, psychological, and social condition—not a purely somatic one.

Central sensitisation, trauma burden, mood dysregulation, cognitive overload, and neuroimmune change cannot be managed through biomedical pathways alone. Yet most pain services still function as though the nervous system is separate from emotion, memory, identity, and threat perception. That separation is not only outdated, it is clinically limiting.

The Pain Collective’s integrated model positions psychiatry alongside physiotherapy, occupational therapy, medical management, psychological support, and rehabilitation planning. This means complex cases are not referred “later”, after failed procedures and escalating medication plans, but are holistically assessed at the outset. This reduces polypharmacy, prevents unnecessary interventions, and accelerates functional recovery.

The data speaks for itself: chronic pain and mood disorders share neural circuitry, inflammatory signalling, neurotransmitter pathways, and vulnerability factors. Ignoring this overlap does not protect patients—it delays effective treatment.

Clinicians who have not yet incorporated psychiatric expertise into their pain pathways may soon find themselves behind the curve. Modern pain science is moving rapidly toward integrated, trauma-informed, nervous-system-aware care. Those who wait until after treatment failures to bring psychiatry in are working against the neurobiology rather than with it.

The Pain Collective model reflects where the field is heading rather than where it has been. For clinicians ready to modernise their practice, the question is no longer whether psychiatry belongs in pain care, but how early it should be included.

If we want truly high-value outcomes in chronic pain, integration is not progressive—it is essential.

  

The role of psychiatry in chronic pain

To understand the role of psychiatry in chronic pain, it is first necessary to understand something about pain.

If you have read anything about chronic pain the opening paragraph is always about how pain is defined:

 “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”

What this means is that in the short term, pain is a protective alarm. After injury or illness heals, acute pain normally settles (often within ~10 days). Acute pain is designed to keep us safe. It is the body’s way of saying: “Stop! Something is wrong. Pay attention!” It focuses our awareness, demands attention, and drives help seeking behaviour. Without it, people would ignore injuries or infections until they caused lasting harm.

The flip-side of this is chronic pain – or pain that lasts beyond the time frame that healing should have occurred, typically 3 months. This definition is so important because this “healing’ is not just about tissue damage - it is also the emotional healing; the return of the increased stress response to normal levels; and a reset of the nervous system’s hypersensitivity back to baseline.  

To manage chronic pain properly, it is important to know the different types of pain which are: :

• Nociceptive pain – due to inflammation or tissue injury e.g. arthritis, cancer pain
• Neuropathic pain– due to a lesion/disease of somatosensory system e.g. post stroke, diabetes, spinal cord injury
• Nociplastic pain – pain due to altered nociception despite no clear tissue damage or nerve lesion e.g. tension headache, fibromyalgia or irritable bowel syndrome
• or a mixed picture e.g. psoriatic arthritis with fibromyalgia

Depending on the physiological mechanism, and the type of pain, different medications and intervention strategies will be needed. Not knowing what type of pain is being treated leads to misdiagnoses and unnecessary treatments - and frequently polypharmacy. A comprehensive biopsychosocial assessment is therefore essential in the management of both acute and chronic pain.

Psychiatrists are often called upon to help determine a clear diagnosis of the type and mechanism of pain that may be contributing to someone’s clinical presentation. The reason for this is that pain is not just something that happens in, or to the tissues – chronic pain impacts every aspect of a person’s being, how they interact with their environment, and how they engage with other people. Pain is a multidimensional, biopsychosocial phenomenon.

Considering pain from a biopsychosocial perspective.

The Biological dimension: mechanisms, sensitisation, and the “over-sensitive alarm”

Central sensitisation

At the core of the biological processes in chronic pain is central sensitisation. This is when the amplification of neural signalling within the central nervous system produces hypersensitivity. It can follow top-down changes (for example altered brain network connectivity and weakened descending inhibition) and bottom-up changes (for example spinal dorsal horn hyperexcitability and widened receptive fields). The consequences of this hypersensitivity include sensitivity to touch, temperature, light, sound, odours, stress, and a poorer response to endogenous analgesia and opioids.

Central sensitisation is essentially an overactive threat response to input from the environment that can be either noxious or non-noxious. 

Pain is actually really useful! It is how our body protects us from potential threats, which can be so much more than just physical threats. With chronic pain, these threats can be any external stressors, e.g., a fight with a co-worker, financial worries, concerns about a meaningful relationship or a myriad of other factors. The analogy I like to use to explain this concept to patients is that of the ‘over-sensitive alarm system’. 

Let us say that your house has been broken into. In order to prevent this from happening again, you hold a family meeting. Together, you decide to get burglar proofing installed, an electric fence, security cameras and infrared scanners. You are sure this state-of-the-art defense system will protect you and set off an alarm, should there be any new threat to your home.

The problem is it now works too effectively, and one evening, a lizard walks across the camera, setting off the alarm system. The local  security response team, the SAPS and the entire WhatsApp neighbourhood group arrive at your house to help, but the lizard was never a threat - the fault was with the alarm system that was too sensitive to being triggered! 

The same thing happens within the nervous system of someone with chronic pain. To protect a person from potential threats, certain changes occur within the body to create a hyper alert defense system. These may include changes in receptor types in the dorsal horn of the spinal cord; a change in the way neurons talk and communicate with each other in the spinal cord; as well as changes in how the brain processes or responds to information. 

One of the main changes is to the sensitivity or responsiveness of the thalamus (the part of the brain that decides whether incoming messages deserve attention or not). The thalamus now becomes overly responsive.

As a result of this over-responsiveness of the thalamus, the brain gets flooded with messages that are perceived to be a threat, even when they may not be. These messages undergo further processing in the brain. Emotional responses are added, related to how someone feels about the threat and how they then choose to respond. 

The magnitude and volume of this information can affect cognitive processes, often accumulating in the experience of brain fog and memory problems. 

The problem with this hyper-reactivity is that things which should not normally cause pain, can trigger this alarm system.. Something seemingly ‘unrelated’ like worrying about medical bills may set off the alarm system with the result that pain may flare up, even when ‘nothing has changed’.

A really important point though, is that the changes to the spinal cord and brain described above, are functional and structural physiological changes, and hypersensitivity symptoms are therefore very real and fortunately, also have very real treatment targets.

Psychosocial dimension

Pain is deeply personal, and the experience may be coloured by what was going on in the person’s life at the time the injury or incident, and everything that follows after.  This may include emotional and physical trauma of the actual incident, but also trauma that occurred earlier in life that may be reactivated.

If we follow a purely biomedical approach – one that ignores the impact that our emotions and mental health have on chronic pain, we are going to be unsuccessful in treating it.

The risk for us as healthcare providers is that if you only have one tool in your toolbox, e.g. pain medication, or massage, or surgery, what do you do when this doesn’t work? With the best intentions in the world, medical professionals run the risk of engaging in polypharmacy, or recommending unnecessary interventions and treatments if a patient ‘doesn’t respond’ to their treatment. 

It is at this intersection between the biological and the psychosocial, that psychiatry comes into its own.

As a psychiatrist, my role in managing chronic pain often surprises people. But the truth is, pain isn’t just physical.

It impacts mood, sleep, relationships, and quality of life. Many people living with pain face anxiety, depression, and trauma. 

Treating the mind is just as important as treating the body. Modern science shows us that all thoughts and emotions influence and change our physiology. The pain of social rejection activates the exact same brain areas as physical pain. This means that the time when we could separate the mind from the body has long gone, and should remain, firmly, in the past. 

 

A whole-person approach to pain management

Chronic pain requires a holistic approach – considering body, mind, soul, and context. This might involve prescribing medications that reduce pain sensitivity,  psychotherapy to build resilience, and collaboration with physiotherapists, occupational therapists, dieticians etc to create individual integrated care plans.

Helping someone with chronic pain isn’t just about symptom control - it’s about empowering them to live well despite the pain. To reconnect with their identity, find meaning, and regain a sense of agency. Mental health care is essential to this process. And that’s why psychiatry belongs in the chronic pain conversation.

The link between mood disorders, chronic pain and trauma

Chronic pain and mood disorders share vulnerability factors and neurological pathways. Vinall et al., refer to mood disorders and chronic pain conditions as ‘syndemic’.

Syndemic refers to the interaction of two or more comorbidities that have overlapping or interwoven biological pathways, and the conditions are influenced by the same determinants of health.

These determinants of health include: the social and economic environment, the physical environment, and the person’s individual characteristics and behaviours.

The conceptual model of a syndemic framework links adverse social experiences such as childhood abuse, poverty and unemployment with chronic pain and psychological distress.

If we consider our South African context, it is not surprising that the prevalence data of 1 in 5 adults echoes that of the rest of the world.

It is clear from multiple studies on the impact of social experiences such as trauma, that exploring this (both present and past) should form part of our assessment when we work with someone with chronic pain.

A large majority of South Africans are exposed to trauma, with some studies finding as many as 86% to 91% of South Africans having experienced at least one traumatic event. The prevalence of exposure is high across the population due to a variety of traumatic events, including violence, accidents, and the loss of a loved one

Research also shows that many children experience adverse childhood experiences (ACEs), with one study indicating that 6 out of 10 South African children will have experienced at least one adverse event by age 17.

Adverse childhood experiences are defined as repeated negative experiences that represent a deviation from what is accepted as normal and require adaptation.

An example of such trauma might be childhood abuse, or other adverse childhood experiences such as parental illness, criminality, violence, neglect, and poverty. These potentially traumatic experiences can have long-lasting effects on health and well-being..

Physiologically, trauma can lead to a hyperarousal state at the time of the occurrence, which disrupts normal brain development, causes dysregulation of the HPA axis and increases the risk of medical conditions such as cardiovascular disease, obesity, depression and chronic pain across the lifespan.

The greater the number of traumatic life events experienced in childhood, the more the risk increases for developing conditions such as depression and chronic pain.

When resilience is further weakened by additional stressors, such as poverty and unemployment, a hyperarousal state is continually triggered, which can lead to both the onset and persistence of adult mental health disorders and chronic pain conditions.

While we have some understanding of the pathophysiological mechanisms underlying the neurobiological overlap between chronic pain and depression, researchers continue to explore why these conditions are so intimately linked. 

Depression and chronic pain share neural mechanisms. When we look at functional neuroimaging studies, we see that overlapping brain areas are activated in chronic pain, depression, and anxiety. Examples include the brain regions responsible for processing emotional stimuli, namely the insula, anterior cingulate cortex, and the prefrontal cortex.

Noradrenaline and serotonin are  both implicated in the pathophysiology of mood disorders and chronic pain conditions. New research shows that the GABAergic system is involved in influencing serotonin, noradrenergic, and glutamatergic pathways.

This system also affects neuroplasticity through the actions of brain derived neurotrophic factor, stress, and the HPA axis, immune-inflammatory pathways, and oxytocin.

To make it just a little more complicated, we now know that microglia are also implicated by their effect on different inflammatory pathways, cytokines, and neurotransmitter metabolism in the brain. With these changes, there is an elevation of pro-inflammatory markers, as well as changes in glutamatergic transmission.

It is clear that Psychiatrists are particularly well positioned to explore the complexities and overlaps that arise in the nervous system of someone living with chronic pain.

Treatment overlap

Chronic pain disorders are not just associated with mood disorders and anxiety, but also often associated with a variety of other co-morbid mental health illnesses such as substance use disorders, post-traumatic stress, personality disorders, and an increased risk of suicide.

Because mental health conditions and chronic pain disorders are so interconnected in terms of their pathophysiology, they also have a significant treatment overlap – and this is where psychiatry, as part of the multidisciplinary team, comes into its own.

Psychiatrists are well versed in the use of medications that target the neurochemical pathways involved in both pain and mental health and have specialised knowledge in the prevention and treatment of substance dependency.

The psychiatrist is therefore often responsible for the pharmacological management of both the mental health and the pain condition, since the shared neurotransmitters and brain areas mean that both might respond to medications such as, for example SNRIs (Duloxetine) or tricyclics such as Trepiline.

Pharmacology, however, just like any other treatment modality cannot stand in isolation, and forms part of a biopsychosocial treatment plan.

A biopsychosocial treatment team might include a general practitioner, psychiatrist, psychologist, occupational therapist, and physiotherapist.

Within this biopsychosocial treatment plan, chronic pain and mental health conditions may also respond to similar non-pharmacological therapeutic treatments. These conditions have mutually maintained cognitive biases affecting both attention and memory as well as behavioural factors such as sleep disturbances. Effective therapies include cognitive behavioural therapy (CBT), Acceptance and Commitment Therapy (ACT), Dialectical Behaviour Therapy (DBT) and Mindfulness based interventions.

Therapies such as CBT and ACT are effective in targeting avoidant beliefs (maladaptive cognitions), fear and anxiety (maladaptive emotions) and avoidant behaviours (or a set of maladaptive behaviours).

Dialectical Behaviour Therapy (DBT) can be really helpful here too. The focus of DBT is on teaching skills to manage intense emotions and pain flares, crisis survival skills; skills to regulate emotions; improve self-efficacy; improve interpersonal relationships and communication; and to practice radical acceptance and mindfulness.

Mindfulness-based interventions help to cultivate cognitive, emotional, and behavioural flexibility. The aim of these interventions is not to change the awareness of pain but rather to change how individuals react to the emotions and thoughts associated with living with chronic pain. It is this separation of awareness from response which helps bring about positive behavioural changes. 

Other techniques that can be taught to help reduce stress and to trigger a parasympathetic response include relaxation training e.g. diaphragmatic breathing, progressive muscle relaxation and imagery. The goal of all these therapies is to assist  in developing healthy coping strategies.

Therapy teaches how to use active problem-solving skills so that people living with pain can self-manage pain-related thoughts and beliefs. Part of therapy is teaching  how to challenge maladaptive thoughts. The goal may not be to achieve a pain-free life, but rather a good life despite pain.

So next time you want to suggest a referral to a psychiatrist to your patient, explain that it is NOT because you think their pain is all in their head, but rather that they deserve an expert in  understanding the overlap between pain and mental health, and that you are aiming for treatment from a whole-person point of view.

There is no single silver bullet treatment for complex chronic pain, and your friendly neighbourhood psychiatrist may just have one or two biopsychosocial trump cards up their sleeve!

Dr Michelle King