Choosing Well: A Narrative Review on Chronic Pain and Decision-making

Abstract

Chronic pain is one of the most prevalent and costly health conditions in the United States. Previous work has demonstrated that chronic pain impacts cognition and behavior. However, the impact of chronic pain on daily decisions is less well-known. This narrative review identified and synthesized findings from a literature search that yielded 18 peer-reviewed, experimental, cross-sectional studies on the effects of chronic pain on different decision-making outcomes. According to the literature, the effects of chronic pain on decision-making are evidenced by 1) reduced decision performance, 2) increased risk-taking and delay discounting, 3) altered sensitivity to outcomes, and 4) reduced cognitive flexibility and learning. Chronic pain effects on decision-making also vary by individual factors such as sex/gender, age, and affective and social factors. Guided by these findings, current limitations and future directions in the field are discussed.

Perspective:

This narrative review highlights current evidence and identifies critical knowledge gaps, emphasizing a need to better understand the relationship between chronic pain and decision-making. Findings can guide future theory and shape interventions aimed at improving decision-making in chronic pain.

I. Introduction

Whether it’s making a purchase, volunteering, screening for cancer, or interacting with others, our daily decisions contribute to our overall health and well-being. The ability to choose well can be impacted by a myriad of reasons relating to one’s individual characteristics and experiences, including age ^1,2, impulsive traits ³, and exposure to stress ⁴, to name a few. Previous work has also linked certain health conditions to impairments in decision-making, such as substance use disorders ^5,6 and brain damage ^7,8.

The experience of pain is one major, yet understudied, factor that can influence decision-making ⁹. For example, acute pain induced in healthy humans ¹⁰ along with related factors, such as the threat of pain ¹¹, have been associated with riskier decision-making in the laboratory (See Box 1). However, the impact of chronic pain on decision-making is not well characterized yet ^12-14. Understanding the role of chronic pain in decision-making is critical, given that chronic pain affects more than 20% of the population ¹⁵, incurs enormous societal costs (i.e., $560-$635 billion annually in the US ¹⁶), and diminishes quality of life and health outcomes across the lifespan ^17,18.

Box 1. Decision-making in Experimental Settings.

Decision-making spans multiple domains (e.g., monetary, social, and health ⁹⁵) and vary in their complexity in the real world. Forming a value-based decision involves evaluating subjective costs and benefits, alternative paths, prior experience, and other informational inputs. In experimental settings, various decision-making paradigms have been developed to systematically examine the cognitive, emotional, and behavioral components involved before, during, and after decisions are made. Figurative and actual monetary gains and/or losses under varying conditions of certainty and risk are among the most common outcomes of choices made in these paradigms ⁹⁶. Among the more commonly used paradigms in experimental research is the Iowa Gambling Task (IGT) ⁸, a card selection task that taps into uncertainty and reward present in real-world decision-making which has been widely investigated in clinical populations. Variations of the IGT have also been utilized, which incorporate changes in reinforcement schedules (e.g., time delay ⁴⁵ or stimulus features (e.g., faces ⁹⁷) to assess potential choice biases and cognitive strategies. Delay discounting tasks are other well-investigated decision-making paradigms that help uncover factors, such as impulsivity, that affect the valuation of certain rewards/punishments and subsequent choices.

More recent variations of decision-making experimental tasks have explored how social- and health-related rewards and consequences also impact decision-making processes ^44,95 and can even model interactions with social partners (e.g., the Ultimatum Game). Other ecologically valid tasks have been designed to represent complex yet everyday choices, such as consumer decision-making ²⁶. Task switching assesses shifts in attention relevant to decision-making ⁹⁸. Additionally, associative learning tasks have also been useful for determining how one’s ability to integrate and discriminate between past associations can impact preferences and behavioral choice ^27,40.

Chronic pain adversely impacts cognition and the brain (See Box 2), which can affect decisions relevant to navigating everyday life, including coping with and seeking relief from pain ^12,19. Further, chronic pain has the potential to influence not only everyday decisions but also more consequential and emotionally charged decisions, such as whether to undergo and adhere to certain medical treatments²⁰ or plan advance care²¹. Although the impacts of chronic pain on cognitive functioning ^22-24 and the brain ²⁵ are discussed elsewhere, less attention has been devoted to its effects on decision-making, in particular ^9,12. This narrative review synthesized current evidence to identify the paths by which chronic pain may possibly alter decision-making. The methodology of the literature search is described below. See Supplementary Table 1 for a glossary of relevant cognition and decision-making terms. Current limitations and future directions are also discussed in light of the need for greater theoretical development, investigation across populations and decision-making domains, and developing evidence-based interventions in this area.

Box 2. Pain in the Brain.

Functional impacts of chronic pain: In chronic pain patients, impaired cognition, emotion, and decision-making ^22,24,35,83 parallel altered brain function and structure ^99-102. These alterations occur within brain regions that are both related ^103,104 and unrelated ^19,99 to pain processing. Certain regions impacted by chronic pain, such as the prefrontal cortex, are involved in the sensory and affective components of pain processing as well as critical cognitive processes necessary for decision-making and learning ^12,27. More specifically, the medial prefrontal cortex (mPFC), which plays a prominent role in processing the emotional, motivational, and cognitive components of pain, is shown to have increased activation in response to spontaneous and sustained pain in patients with chronic back pain ¹⁰³.

Increased activation in the mPFC is also a potential indicator of disrupted functioning within the default mode network (DMN) among chronic pain patients. Furthermore, previous work has observed decreased connectivity between the mPFC and posterior components of the DMN. In contrast, connectivity between the mPFC and the insular cortex appears to increase among individuals with chronic back pain, knee osteoarthritis, and complex regional pain syndrome relative to healthy controls, which may signify a shift of pain from a nociceptive sensory state to an emotional burden, further evidenced by the disruption of DMN suppression ¹⁰⁵. It is critical to note that chronic back pain patients performed comparably to healthy controls in a behavioral visual attention task, despite exhibiting disturbed DMN dynamics. DMN disruption also increased according to pain duration in those with chronic back pain ⁹⁹. This disruption in DMN activity has been suggested as a potential mechanism for the cognitive and behavioral impairments observed in chronic pain ⁹⁹.

The nucleus accumbens (NAc) is another brain region impacted by chronic pain that is associated with reward processing. Demonstrating this, functional connectivity of NAc with prefrontal regions of the brain at rest was reduced in chronic back pain patients and later corresponded to a greater degree of impulsivity during monetary decision-making compared to healthy controls ⁴⁶. Similarly, use of the IGT suggests that functional impairments in the orbitofrontal cortex (OFC) may lend to impaired decision-making ^19,39,43. Though the exact mechanisms by which the OFC dysregulation in chronic pain results in decision-making deficits are unclear, it has been thought that chronic pain disrupts signals from the prefrontal regions, insula, and amygdala that are integrated through the OFC ¹⁹.

Structural impacts of chronic pain: Chronic pain is associated with structural atrophy in brain regions such as the dorsolateral prefrontal cortex (dlPFC) ^99,101,103, which plays a critical role in the cognitive components of pain processing ⁹. Structural change (e.g., reductions in grey matter) may reflect neuronal loss in the dlPFC. Volumetric reductions in grey matter density among chronic musculoskeletal pain patients were also noted in the somatosensory, motor, and cingulate cortices ¹⁰⁶. Several studies have also shown partial grey matter recovery when chronic pain is alleviated (for a review, see ¹⁰⁷).

Moreover, total cortical grey matter volume is positively correlated with IGT performance in chronic pain patients but not healthy controls, which indicates increased recruitment of cortical resources for decision-making relative to healthy controls ^30,106. Subcortically, chronic pain patients have been found to have reduced NAc volume, potentially contributing to dysregulation of the reward circuitry in the brain and lending to the risky decision-making patterns observed in chronic pain patients ^30,108. Specifically, lower grey matter volume in the NAc was associated with higher rates of pain catastrophizing among fibromyalgia patients ^101,109. Other subcortical structures, such as the caudate and the thalamus, appear to be larger with higher grey matter volumes in chronic musculoskeletal pain patients, while evidence regarding the effect of chronic pain on the hippocampus and amygdala is mixed ¹⁰⁶. This increase in subcortical volumes coupled with decreases in frontal brain region volumes may provide further evidence of chronic pain processing shifting from nociceptive to emotional processing circuits, which furthermore may influence decision-making ^106,110. Taken together, there is evidence for functional and structural impacts of chronic pain with relevance to processes that support decision-making. However, more consistent work is needed across pain conditions.

II. Chronic pain can alter cognitive functions that support decision-making.

Chronic pain can alter various interrelated cognitive functions critical for decision-making, including, but not limited to, attention ^26-28; processing speed ²⁴; memory ^24,26,27; reward processing ^29,30; task switching ³¹; emotion processing (e.g., difficulties in emotion regulation ³²; and increased negative emotional states ²²). Cognitive changes in people with chronic pain may also include reduced neuropsychological performance ³³ and impaired learning ^13,29,34.

Individuals with chronic pain can experience increased executive dysfunction, including disrupted attention, planning, and problem-solving associated with day-to-day activities ^26,35,36. These impairments have far-reaching impacts on goal-oriented cognitive processes, such as the ability to focus attention, assess information, and execute plans ³⁶. Chronic pain is also associated with other cognitive challenges, such as impairment in set-shifting and response inhibition³⁶. Baker et al. found that executive dysfunction in chronic pain was prominent across working memory and emotional control processes ³⁵. Moderating factors, such as negative emotional state, were also significant predictors of executive dysfunction ³⁵. Additionally, Attridge and colleagues demonstrated that recurrent pain disrupted basic attention processes, potentially leading to poorer decision-making in an ecological shopping task relative to pain-free individuals ²⁶. This finding illustrates how cognitive disruptions can impact day-to-day decision-making in individuals with chronic pain, including the ability to evaluate potential outcomes thoroughly.

Though some have observed that pain can act as a competing influence on cognition and related task performance ¹³, others report mixed evidence²⁴ or small effects³⁶ for executive dysfunction in people with chronic pain. These inconsistent findings on executive dysfunction may reflect that specific cognitive impairments associated with chronic pain may be too subtle to be detected by standardized neuropsychological assessments²⁷. See also ³⁷ for no effect of chronic pain on logical reasoning.

The relationship between pain and cognition is complex, and some theorize that pain and cognition are reciprocally linked^9,28. Further, investigations on the effects of chronic pain on cognition are currently limited by the lack of consideration of critical moderators such as sleep quality, pain duration and intensity, and medication use³⁶. For example, certain analgesic medications used for pain management have been linked to cognitive impairment in individuals with chronic pain^28,38. Cognitive status before the onset of pain may also play a role in exacerbating chronic pain-related disability and distress, and is critical to consider when examining decision-making outcomes of specific groups of people with chronic pain, such as older adults with mild or more advanced cognitive impairment^21,38.

III. Chronic pain can influence decision-making and learning.

Methodology of Literature Search.

Despite limited research to date, the impacts of chronic pain on decision-making have been documented across a range of experimental contexts (See Box 1). Therefore, a narrative review was completed as a first step to gauge the state of this emerging subfield and offer a conceptual discussion on opportunities for progress. To ensure that the most current literature was included in this narrative review, a literature search was conducted on a rolling basis starting in September 2021 until July 2025. Search terms included: “pain,” “chronic pain,” “decision(s),” “decision-making,” and “choice(s).” Google Scholar, PubMed, and an internal reference management library were used to identify relevant papers. Only peer-reviewed, published empirical studies on chronic pain and decision-making were considered for full review. Preprints, preregistrations, literature reviews, protocols, trials in progress, conference proceedings, commentaries, and case studies were excluded from this search. Though important to consider in future synthesis, research topics including the effects of acute/experimental pain on decision-making, findings on pain and decision-making in healthy populations, and work on clinical and shared decision-making outcomes were outside of the scope of this review. A web-based tool called Covidence (www.covidence.org) was used to help streamline the literature identified in the search. The first author imported 190 references for screening, and 18 peer-reviewed, experimental, cross-sectional studies meeting the scope of this search were selected for full review (See Table 1).

Table 1.

Overview of selected studies on chronic pain and decision-making.

	Age (in years)	Sex/Gender	Pain Condition( s)	Healthy Control Group ?	Decision-making Measure(s)	Main Finding(s)
Clinical Work
Apkarian et al., 2004	HC: 24-64 (Mean = 43.6) CBP patients: 21-71 (Mean = 43.7) CRPS patients: 21-56 (Mean = 42.9)	M/F	CBP and CRPS	Yes	IGT	CPS and CRPS patients exhibited impaired decision-making and switched between decks more often than HC. CRPS patients performed worse than CBP patients and HC. HC and CBP patients learned to make better decisions over time, though this was delayed in CBP patients. CRPS patients did not show improvement over time. Chronic pain intensity was negatively correlated with task performance in CBP patients but not in CRPS patients.
Montoya et al., 2005	HC: 43-60 (51.75 ± 5.66) FM: 40-58 (50.58, ± 6.19)	F	FM	Yes	Language-based decision-making task	HC and FM patients did not differ in pressure pain thresholds or behavioral reactions to the task. Unpleasant pain-related words elicited more positive ERP amplitudes than emotionally neutral words in HC but not FM.
Verdejo-Garcia et al., 2009	HC: 32-58 (44.97 ± 6.70) FM: 34-58 (45.86 ± 6.78)	F	FM	Yes	IGT and Variant IGT (EFGH)	Learning curve found among HC but not FM patients for IGT. No significant group difference in IGT and Variant IGT total net score. Self-reported pain intensity and pain interference were associated with block 3 of IGT. No significant group differences in learning or total net score for the Variant IGT.
Walteros et al., 2011	FM: 42-59 (50.40 ± 4.60) HC: 39-61 (49.00 ± 6.70)	Not specified	FM	Yes	Conditional Associative Learning Task (CALT) and IGT	FM patients had poorer performance and more preservation errors than HC in the CALT. FM patients had poorer performance and more random behavior than HC in the IGT.
Biagianti et al., 2012	Chronic migraine with medication overuse: 42.70 ± 11.00 Episodic migraine: 42.10 ± 9.70 HC: 40.70 ± 10.30	M/F	Chronic migraine with medication overuse and episodic migraine	Yes	IGT	Both migraine groups performed worse than HC in IGT, making more risky and disadvantageous choices.
Berger et al., 2014	CBP: 45.90 ± 7.80 HC: 36.60 ± 6.94	M/F	CBP	Yes	Loss aversion monetary gambling fMRI task	CBP patients were more gain sensitive than HC. This behavioral difference was not explained by current pain ratings. No group difference on task-related brain activity or reaction time. Resting-state modular connectivity of the nucleus accumbens differed between groups (i.e., CBP patients showed more connectivity to subcortical structures than frontal regions compared to HC). CBP patients’ resting state connectivity resembled that of healthy but highly impulsive individuals from a separate study.
Elvemo et al., 2014	PCP: 38.50 ± 7.10 HC: 38.40 ± 7.00	M/F	Mixed etiology of chronic pain	Yes	IGT	PCP did not show anticipatory skin conductance responses before making unfavorable choices, as observed in HC. PCP switched between decks of cards more often than HC. In PCP, task scores positively correlated with total grey matter volume but not in HC.
Hess et al., 2014	FM: 50.40 ± 4.60 HC: 49.00 ± 6.70	Not specified	FM	Yes	IGT	Less persistent choices and more gain sensitivity in FM patients than HC.
Tamburin et al., 2014	CBP: 35-69 (47.70 ± 9.10) HC: 23-71 (46.10 ± 17.50)	M/F	CBP	Yes	IGT	CBP patients accumulated less money, showed no learning strategy, and had abnormal feedback processing compared to HC during the IGT.
Attridge et al., 2016	18-75	M/F/NB	Study 2 and Study 3: Mixed etiology of current and recurrent pain conditions	Yes	Multiple switching tasks	Study 2: Current pain, was associated with lower accuracies than HC, but no increased task switching costs. Study 3: No evidence of increased accuracy switch cost due to pain.
Tompkins et al., 2016	Low opioid misuse risk: 49.60 ± 12.70 High opioid misuse risk: 45.40 ± 11.20	M/F	Mixed etiology of chronic pain	No	4 delay discounting tasks (i.e., Monetary Choice Questionnaire (MCQ), modified MCQ for monetary losses, Pain Relief Choice Questionnaire, and the Additional Pain Choice Questionnaire)	PCP with high opioid misuse risk were less likely to choose smaller-sooner punishments compared to PCP with low opioid misuse risk. No association with delay discounting of rewards.
Attridge et al., 2019	18-74	M/F/NB	Mixed etiology of current and recurrent pain conditions	Yes	Online shopping-decision task and Decision Outcomes Inventory	Current, but not recurrent, pain was related to more errors in the shopping task. PCP scored lower (i.e., more negative events) on the Decision Outcomes Inventory than HC.
Timm et al., 2021	PCP: 49.75 ± 14.64 HC: 40.35 ± 15.08	M/F	Chronic pain disorder with somatic and psychological factors	Yes	Ultimatum Game and Roulette Betting Task	PCP rejected more offers than HC in the Ultimatum Game, especially for unequal offers. No significant group difference in betting amounts or risk adjustment in Roulette Betting Task.
Craft et al., 2022	38.14 ± 10.83	M/F/NB	Mixed etiology of chronic pain	No	Delay discounting	Greater discounting of delayed rewards predicted greater perceived stress related to the COVID-19 pandemic among PCP. Magnitude of perceived stress fully mediated relationship between delay discounting rate and overall pain severity in PCP during the COVID-19 pandemic.
Bialaszek et al., 2023	PCP: 42.42 ± 16.78 HC: 26.02 ± 5.05	M/F	Mixed etiology of chronic pain	Yes	Delay discounting of pain and monetary losses	PCP discounted delayed pain outcomes more than HC. No difference in discounting monetary losses. Pain anxiety mediated the effects of chronic pain on delay discounting.
Tanik & Ozer Kaya, 2024	18-65 (50.82 ± 10.79)	M/F	CNP	No	Melbourne decision-making scale I-II	Activity pain, night pain, and neck disability were negatively correlated with a careful decision-making style. Night pain and neck disability were also negatively correlated with self-esteem in decision-making.
Preclinical Work
Pais-Vieira et al., 2009	Not specified	M	Sprague-Dawley rat model of monoarthritic inflammatory chronic pain	Yes	Rodent gambling task (analogous to IGT)	Rats with chronic pain preferred immediate larger but infrequent rewards (i.e., higher risk) and had decreased tonic levels of dopamine, DOPAC, and 5-HIAA in orbitofrontal cortex tissue but not the amygdala or nucleus accumbens compared to HC.
Cowen et al., 2018	Not specified	M	Sprague-Dawley rat model of chronic neuropathic pain (i.e., spinal nerve ligation)	Yes	Associative learning tasks (i.e., Choice Task and Variable Ratio Choice Task)	Rats with chronic pain were impaired in learning optimal behavioral strategies compared to HC but also engaged in a novel learning strategy.

Abbreviations: CBP = Chronic back pain; CNP = Chronic neck pain; CRPS = chronic complex regional pain syndrome; M = male; F = female; FM = Fibromyalgia; HC = Healthy controls; IGT = Iowa Gambling Task; NB = Non-binary and/or transgender; PCP = Patients with chronic pain

Overview of findings.

First, it is essential to note that conclusions drawn from these studies are limited, partly due to the breadth of chronic pain conditions and decision-making outcomes examined. That is, whereas some studies exclusively examined decision-making outcomes in specific chronic pain conditions (e.g., chronic back pain, chronic migraine, and fibromyalgia), other studies included a mixed etiology of chronic pain conditions. Additionally, the reviewed studies primarily focused on decision-making outcomes related to non-social gambling and delay discounting. For example, eight reviewed studies examined decision-making using the Iowa Gambling Task (IGT, description of task in Box 1) or an analogue task (See Table 1). Additionally, only two studies were conducted on preclinical animal models of chronic pain ^39,40, and all others were performed in humans. Two studies did not include a healthy control group ^14,41.

Thus, the state of the field is still nascent, and the available studies do not cover all of the decision-making domains that are relevant to chronic pain. Despite these current limitations, findings from these studies were synthesized and collectively demonstrate that chronic pain is associated with 1) reduced decision performance, 2) increased risk-taking and delay discounting, 3) altered sensitivity to outcomes, and 4) reduced learning and cognitive flexibility (See Figure 1, described in detail below).

Figure 1: Depiction of the Associations between Chronic Pain and Decision-Making Based on Published Findings.

Solid lines represent known associations based on published findings, whereas dashed lines represent understudied associations.

Lower Decision Performance Compared to Healthy Controls.

One consistent behavioral indicator of impaired decision-making across studies was lower decision performance. Decision performance can be objectively measured by tabulating outcomes of decision-making tasks such as net scores ^13,27,42,43, wins vs. losses ¹³, and perseveration errors ²⁷. Generally, individuals with chronic pain of mixed etiology perform worse on decision-making tasks compared to healthy controls ^13,27,42,43. These studies report poorer performance across multiple pain conditions, including fibromyalgia ²⁷, chronic back pain ^13,42, complex regional pain syndrome (CRPS) ⁴², and chronic migraines ⁴³. Behavioral differences in decision performance may be further magnified between specific pain conditions ⁴². For example, people with CRPS performed worse than those with chronic back pain in the IGT. Although CRPS and chronic back pain involve localized pain in specific body areas, these conditions differ in their manifestations (e.g., pain onset, intensity, duration), disability, and treatment. For example, CRPS patients routinely receive sympathetic blocks to temporarily relieve pain from nerve damage, whereas chronic back pain can be conservatively treated through over-the-counter antiinflammatory pain relievers and physical exercise. Thus, the behavioral differences observed between pain conditions could possibly be attributed to underlying factors unique to these populations. In this example, pain severity and chronicity were investigated factors that did not explain behavioral differences between groups ⁴². Further investigation is needed to characterize underlying differences in decision-making between pain conditions, including other pain-related factors, such as emotional reactivity to pain (e.g., catastrophizing, fear) and interference with daily life and well-being.

Other studies did not find a significant difference between individuals with chronic pain and healthy controls in decision performance, such as in the form of betting amounts and risk adjustment in Roulette Betting Task in chronic pain disorder ⁴⁴ or net scores in IGT in fibromyalgia ⁴⁵. The lack of group-level behavioral differences in the latter studies may be due to factors requiring more systematic investigation, including adequate assessment of cognitive functions impacted by chronic pain, the design and measurement of decision-making tasks, and population characteristics.

Increased Risk-Taking and Delay Discounting.

Chronic pain has been associated with making riskier choices ^46,47. For example, people with chronic back pain accepted riskier offers (i.e., offers of large potential monetary gains as well as losses) in a gambling task compared to healthy controls ⁴⁶. Similarly, individuals with fibromyalgia, compared to healthy controls, preferred selecting from disadvantageous decks in the IGT, leading to potentially higher immediate gains and future loss ⁴⁷. Additionally, certain features of chronic neck pain, such as greater activity pain, night pain, and neck disability, were correlated with a less careful decision-making style as measured by the Melbourne Decision-Making Scale ⁴⁸. Risky decision-making in chronic pain may be attributed to factors such as brain changes in reward and pain processing (See Box 2) as well as greater emotional distress related to their pain experience, which may impair cognition and learning ^11,49.

Risk-taking is also conceptually related to delay discounting, a facet of intertemporal choice that reflects a preference for smaller, sooner rewards over larger, future rewards ^27,39,42. Increased delay discounting has been observed in various clinical populations impacted by psychological dysfunction, including depression and addiction (but see ⁵⁰). Delay discounting has also been associated as a predictor of stress and pain severity in people with chronic pain ⁴¹. Pain anxiety has also mediated the relationship between chronic pain and the delay discounting of pain and monetary losses ⁵¹.

Risk-taking observed in experimental settings may map onto the processes involved in risky health behaviors to self-manage pain observed in the real world among individuals with chronic pain. These health risk behaviors include smoking, alcohol use, and medication overuse/misuse ^14,43,52. Reciprocally, substance use and medication overuse may also have lasting effects on behavior in those with chronic pain and can exacerbate their pain-related experiences ⁵³. For example, relative to healthy controls, medication overuse for headaches in individuals with chronic migraines was associated with a higher risk preference for short-term rewards despite long-term consequences. This preference persisted even after a detoxification period from medication overuse, mirroring risk-taking behavior observed among individuals with substance use disorders and orbitofrontal cortex impairment ⁴³.

Chronic pain-related changes to reward circuitry in the brain may drive preferences for more risky behavior. For example, among animals with chronic pain, a preference for higher-risk options was accompanied by lower dopamine levels in the orbitofrontal cortex (OFC), which indicates decreased OFC activation and cognitive impairment relating to decision-making ³⁹. The brains of people with chronic pain also seem to resemble those of healthy individuals with high impulsivity, as evidenced by comparable modular connectivity structures ⁴⁶. However, more attention is needed on the neurobiological mechanisms underlying the pain-related alterations to cognition and decision-making to better understand the extent of chronic pain effects on risk-taking (See Box 2).

Altered Sensitivity to Outcomes.

In a related fashion, sensitivity to choice outcomes (e.g., reward/punishment, gains/losses) is a critical factor in decision-making. However, current findings on the extent to which chronic pain alters sensitivity to choice outcomes are mixed. On one hand, some individuals with chronic pain experience increased sensitivity to gains compared to healthy controls ^45-47. For example, people with fibromyalgia demonstrated hypersensitivity to rewards, marked by impaired learning in the standard IGT, where monetary gains were immediate, but not during a variant of the IGT, where monetary gains were delayed ⁴⁵. Similarly, individuals with chronic back pain are willing to accept offers with larger potential monetary gains even in the face of larger monetary losses ⁴⁶. Computational modeling of decision-making in people with chronic pain has also shown that behavior in the IGT is driven by potential gains rather than losses or previous experience compared to healthy controls ⁴⁷.

On the other hand, other individuals with chronic pain, such as those at higher risk for opioid misuse, demonstrate increased sensitivity to losses rather than gains ¹⁴. Chronic pain may also heighten sensitivity to losses (i.e., unfairness) during social economic exchanges ⁴⁴. In a similar vein, certain groups of people with chronic pain may also show different behavioral patterns when facing specific types of loss or punishment. For example, one study found that people with chronic pain discounted delayed pain outcomes more than healthy controls. However, no difference was found between groups in discounting monetary losses ⁵¹. Therefore, the prospect of experiencing immediate pain may be a much more salient outcome than potential monetary loss to individuals with chronic pain. Another study demonstrated that individuals with chronic pain at high risk for opioid misuse avoided smaller, sooner punishments in the form of both additional pain and monetary loss. However, no preference for rewards was observed in these individuals ¹⁴. This finding indicates that people with chronic pain who are at a higher risk for opioid misuse are more sensitive to immediate punishments, which, thereby, may lead to overusing prescribed opioids to avoid additional pain now ¹⁴. Generally speaking, pain avoidance is a strong motivational influence that can affect other behaviors that impact quality of life in people with chronic pain, such as interacting with others or engaging in activities that they used to enjoy ⁹. Collectively, these findings indicate that chronic pain increases gain sensitivity and may also affect loss sensitivity, though in specific contexts (e.g., among individuals at heightened risk for substance misuse ¹⁴ or during social interactions ⁴⁴).

Altered sensitivity to outcomes can be linked to differences in neural and physiological functioning in people with chronic pain. For example, in those with chronic back pain, the nucleus accumbens, a brain region highly related to reward processing, was functionally connected to more subcortical regions than healthy controls⁴⁶. Additionally, an abnormal neurophysiological signal (i.e., higher feedback-related negativity amplitude) was observed in individuals with chronic back pain during the presentation of feedback (i.e., wins vs. losses) during the IGT, consistent with a stronger reaction to violated expectations ¹³. Anticipatory skin conductance before disadvantageous decisions in the IGT was also absent in people with chronic pain. This finding indicates that physiological responses that help signal the potential outcomes of decisions may be impaired in chronic pain. Thus, those experiencing chronic pain may rely more heavily on alternative resources (e.g., cortical) to guide their decision-making than healthy controls ³⁰. Chronic pain effects on dopamine may also contribute to abnormal feedback processing during decision-making. For example, lower dopamine levels (as measured by DOPAC and 5-HIAA metabolites) were found among rats with chronic pain that engaged in risky decision-making ³⁹. Neurochemical mechanisms may be involved in chronic pain patients' difficulties adequately weighing potential negative outcomes against immediate rewards. More work, however, is needed to consistently characterize the neural and physiological correlates of decision-making in chronic pain.

Reduced Learning and Cognitive Flexibility.

Chronic pain is also associated with challenges in learning during decision-making tasks ^{13,24,27,29,34}. Some work indicates that people with chronic pain showed reduced ^27,40,42 or no learning ^13,45 during decision-making compared to healthy controls.

Behaviors such as random choices ^13,27 and switching are associated with learning difficulties in decision-making tasks ^30,31,42. However, repetition of tasks may be beneficial for decision-making performance. For example, Apkarian and colleagues found that people with chronic pain performed poorly compared to healthy controls on their first completion of the IGT. However, when instructed to complete the IGT a second time, an improvement in performance was observed. Though individuals with chronic pain were able to learn the IGT over time, they did not perform as well as pain-free controls ⁴². Previous work has also shown that compared to healthy controls, novel, rather than optimal, learning strategies may emerge in decision-making behavior among individuals with chronic pain ⁴⁰.

Individuals with chronic pain also tend to exhibit reduced cognitive flexibility, or the ability to adapt their thinking and behavior in a changing environment, which may stem from avoidance of pain-predictive cues and the negative anticipatory state associated with them ⁹. Pain-related avoidance diminishes opportunities to explore and learn from one’s environment and can have negative cognitive impacts, including fear and catastrophic thinking ⁹. Learned avoidance behaviors are difficult to extinguish, which may lead to relying on habitual or less deliberative decisions ⁹. For example, reduced cognitive flexibility was observed in rats with chronic pain in a rodent gambling task. These animals appeared to learn more slowly and shift from goal-directed behavior to habitual responses over time⁴⁰.

Reduced cognitive flexibility also indicates that those with chronic pain experience difficulties updating the mental strategies needed to maximize performance in a decision-making task. As a result, decisions may appear more random or reflect heuristic preferences. For example, indicators of reduced cognitive flexibility, such as greater perseveration errors ²⁷ and preference for familiar associations⁴⁰ have been observed in chronic pain. These behavioral patterns could, in part, be due to pain-related impairments in working memory, or the cognitive ability to temporarily hold and manipulate information, which is essential for learning and carrying out tasks (see ³⁶ for a meta-analysis on chronic pain and working memory). Though some cognitive processes and behaviors have been linked to suboptimal decision-making in chronic pain, more systematic investigation is needed in human and animal models.

IV. Influence of individual factors on decision-making in pain.

Pain is a highly personal experience. Therefore, when considering how the experience of pain influences our decisions, it is also important to account for the moderating influence of additional factors that vary across individuals ⁵⁴. These individual factors span various biological, psychological, and social domains that interact over time ⁵⁴. The interplay between individual factors relevant to the chronic pain experience and decision-making has only recently been considered, and specific factors will be presented here for brevity (i.e., sex/gender, age, affective and social factors). It is also essential to understand that discussions on individual factors are based on observed associations and do not necessarily offer mechanistic explanations for differences in chronic pain experience or decision-making (e.g., demographics are not direct influencers of pain) ⁵⁴.

Sex/Gender Differences.

Clinical and epidemiological work to date establishes sex/gender differences in the experience of chronic pain. Women are more likely to report experiencing chronic pain and are more at risk of experiencing clinical pain than men ⁵⁴. Additionally, certain pain conditions are more commonly diagnosed among women ⁵⁵, including fibromyalgia ⁵⁶, migraines ⁵⁷, and osteoarthritis ⁵⁸. Men and women also vary in pain expression ⁵⁹, and women with chronic pain may be more vulnerable to poorer psychological outcomes (e.g., depression, anxiety) ^60,61. Sex/gender may be a proxy for individual differences in biological factors that contribute to chronic pain, including hormonal changes ^61,62 and genetic differences ^63,64, as well as social norms surrounding pain beliefs and coping ⁶⁵.

In contrast, there is little understanding concerning sex/gender differences in decision-making among people living with chronic pain. Although many studies investigating decision-making in chronic pain were matched for sex/gender ^13,30,42,43, differences in decision-making by sex/gender were often not reported. One study found that a greater proportion of women exhibited larger-later responses in a delay discounting task of pain relief compared to men. That is, women were more willing to wait to receive more days of pain relief, perhaps exhibiting greater self-control than men¹⁴. A few studies also included men, women, and non-binary individuals in their samples, but significant differences by gender were not found ^26,31,41.

Studies that examined the effects of fibromyalgia on decision-making either exclusively included women ^45,66 or did not specify the gender of their sample^27,47. Although findings indicated that individuals with fibromyalgia performed poorly on decision-making tasks (e.g., IGT ^27,45; conditional associative learning ²⁷), these investigations were not designed to explore potential sex/gender differences. Additionally, the two preclinical studies found on chronic pain and decision-making exclusively examined male rats^39,40.

The lack of sex/gender comparisons in some studies and exclusive examination of one sex/gender in others limits current understanding of this factor’s role in chronic pain and decision-making. For example, the greater prevalence of many chronic pain conditions in women, along with diagnosis and selection bias, may explain why research including men with fibromyalgia is lacking⁵⁶. The practice of excluding females in preclinical research, likely due to variations in the estrous cycle, is another limiting factor that can be remedied in the future⁶⁷. Greater efforts in recruiting sex/gender-matched samples and reporting significant and nonsignificant group-level comparisons will be crucial for closing the gap in understanding sex/gender differences in decision-making among people with chronic pain. When relevant, the rationale for only examining one specific sex/gender should also be provided.

Age-related Differences.

There is evidence for age-related increases, decreases, and stability in pain experience, and this variability in findings has been attributed to differences across pain conditions ⁵⁴ as well as the methodological challenges associated with assessing pain in older populations ⁶⁸. Based on cross-sectional investigations, it is understood that the prevalence of chronic joint, leg, foot, and neuropathic pain increases with age. General chronic pain prevalence also increases with age but plateaus at mid-life. Prevalence of other types of chronic pain, including headaches, abdominal, back, and chest pain, increases with age, peaking at mid-life and declining in later life ⁵⁴. Additionally, cognitive and affective responses to pain change with age, such as higher pain acceptance and self-efficacy and lower catastrophizing than younger age groups⁶⁹, which may reflect broader changes in affect and motivation observed in older adults (e.g., improved emotion regulation; positivity effect ⁷⁰). Further systematic and longitudinal work is still needed to characterize chronic pain experience across the adult lifespan.

Little is known about the impact of age on decision-making in chronic pain. Whereas the age of participants was reported in most published work on humans, age in preclinical studies was not specified^39,40. Mixed-aged and predominantly middle-aged samples have been primarily used in chronic pain and decision-making studies. Additionally, there were no comparisons of chronic pain effects on decision-making by age group, a critical limitation of the current evidence (See Table 1). The age of certain samples in the available literature could have been jointly due to recruitment availability and the prevalence of certain pain conditions by age. No differences in decision-making by age were reported in the papers included in this review. However, Tamburin et al. aptly noted that aging affects decision-making performance, such as the reversal learning effect observed among older adults during the IGT ⁷¹. The reversal learning effect illustrates that older adults can shift away from uncertainty and learn to make more adaptive decisions under risk over time. Whereas comparing net scores between age groups shows that older adults perform worse in the IGT than younger adults, examining trials over time can instead reveal adaptive decision-making patterns within groups.

Future work in chronic pain should open the way for consideration of changes in decision-making across the lifespan ¹³. This future work should reflect samples that are inclusive of older age as well as experimental and data extraction methods that consider the dynamic nature of decision-making in the real-world. Perhaps there are decision-making contexts that can be modeled in future experiments in which maintained or enhanced performance can be observed among older individuals with chronic pain. Identifying and disentangling changes in decision-making due to chronic pain and age is critical moving forward, especially since older adults represent a significant portion of individuals with chronic pain ^17,68 and face complex decisions relating to their health, finances, and social well-being unique to this life stage ¹.

Affective Factors.

The pain experience is not a direct response to nociceptive input but is rather influenced by multiple factors, such as an individual’s affective state ^9,72. For example, chronic pain is associated with negative emotional experiences ^22,73 and mood states, including depression and anxiety ^47,74. Affect also alters cognitive processes critical for decision-making ^27,66, and people with chronic pain may experience unique difficulties in carrying out emotionally-charged decisions ⁴². In support of this, individuals with chronic pain who also report persistent negative moods performed worse on emotional decision-making tasks (e.g., IGT), while their performance on non-emotional cognitive tasks remained intact ²⁷. People with chronic pain also experience difficulties in adopting cognitive strategies to maximize gains on the IGT, which may indicate that their decisions are highly influenced by the immediate emotional relevance of choice outcomes ⁴⁷. In consideration of the impact of negative emotional experiences on individuals with chronic pain, along with the high rates of depression and anxiety in this population, future work will benefit from deeper investigation into the impact of chronic pain on affective states and its influence on decision-making ²⁷, such as through the assessment of baseline characteristics.

Social Factors.

Chronic pain influences social interactions and can strain relationships ⁷⁵, especially if the pain experienced is severe ⁷⁶. Chronic pain, in particular, is associated with reduced social participation ⁷⁷; increased loneliness and isolation ^78,79; and lower relationship quality ^75,80. On the other hand, social connectedness and support are crucial buffers for pain-related stress and symptom burden among patients ⁷² and may enhance their coping with pain ^74,81.

The joint effects of chronic pain on cognition and emotion can impair social functioning²². Specifically, chronic pain may alter perceptions of others and result in social-cognitive impairments, such as difficulty understanding the mental states⁸² and emotions of others⁸³ as well as reduced empathy⁸⁴. Emotion processing, which is important for understanding and engaging with others, is also impaired in those with chronic pain ^82,83. For example, difficulties in emotion regulation, emotion recognition, and theory-of-mind ability have been observed in people with fibromyalgia ⁸².

Although there has been work on how those with chronic pain navigate emotionally charged and nonsocial decisions (See Table 1), little work to date has investigated the impact of chronic pain on social decision-making. Social decisions encompass evaluations and choices that involve others, including trust, reciprocation, collaboration, competition, or retaliation⁸⁵. These decisions are weighed and carried out within complex and dynamic social environments. Understanding how individuals with chronic pain respond across multiple domains of social decision-making is critical for identifying vulnerabilities and potential interventions that can improve social outcomes.

Social decisions can be modeled experimentally via economic games that simulate social exchange (e.g., prisoner’s dilemma game, trust game, ultimatum game)^85,86. Most recently, Timm and colleagues found that chronic pain was related to altered social decision-making (i.e., hypersensitivity to unfair offers from a social partner) compared to healthy controls during an ultimatum game. This behavior (i.e., more rejected offers and inequity aversion) was independent of performance on other non-social cognitive tests and decision-making tasks ⁴⁴, indicating a unique behavioral pattern among those with chronic pain in a social context.

Altered or impaired decision-making in this domain may have real-world consequences for people with chronic pain, contributing to social isolation and reducing prosocial behaviors ⁴⁴. Behavioral responses in social exchanges observed in the laboratory in people with chronic pain can be related to their perceptions of others, including higher perceived rejection, hostility, and injustice ^44,75. Due to the stigmatizing and discriminatory life experiences associated with chronic pain, individuals with chronic pain may develop altered perceptions of others, such as increased perceived injustice⁸⁷ and distrust of others, including medical professionals ^88,89. Patient trust is especially critical when considering the importance of the therapeutic relationship in treatment adherence and outcomes.

Taken together, it is critical to consider the role of individual factors when evaluating the impact of chronic pain on decision-making in the future. Identifying and characterizing the role of moderating factors in pain-related decision-making will guide future research and approaches to managing chronic pain and its emotional, cognitive, and social consequences.

V. Implications for future investigation and intervention.

Theoretical Implications.

Elucidating the linkages between chronic pain and decision-making can enhance understanding of chronic pain development and persistence. It may also influence how clinicians, researchers, and other stakeholders respond to the needs of people with chronic pain through treatment, research, and policymaking. Based on current evidence, the present paper outlines four distinct, but non-exhaustive, paths by which chronic pain may impact decision-making, via: 1) reduced decision performance, 2) increased risk-taking and delay discounting, 3) altered sensitivity to outcomes, and/or 4) reduced learning and cognitive flexibility. However, these paths are unidirectional explanations, demonstrating only how chronic pain influences either cognition or behavior related to decision-making.

In contrast, well-accepted biopsychosocial models have bidirectionally linked chronic pain with factors like motivation⁹, addiction ⁵³, and mood disorders ⁹⁰. It is possible, then, that chronic pain and decision-making may also influence each other in both directions. In other words, this review demonstrates that chronic pain may impair decision-making, but impaired decision-making could make chronic pain worse. Limited research has addressed reciprocal linkages between chronic pain and decision-making, highlighting the need for future studies to consider how decision-making impairments can contribute to the development and maintenance of chronic pain. Such studies could help determine if decision impairments can emerge before the onset of chronic pain and whether decision impairments may contribute to the shift from acute to chronic pain.

Additional research is also needed to elucidate how other biopsychosocial factors may moderate the relationship between decision-making and chronic pain. Linking well-established psychosocial and pain-related factors⁹⁰ to cognitive and behavioral measures of decision-making (e.g., gambling or delay discounting tasks), in both social and nonsocial contexts, could further explicate how decision-making impacts chronic pain, and vice versa. It would also be useful to identify alterations in decision-making that are unique to specific chronic pain conditions versus those that are shared across multiple conditions, perhaps reflecting generalized changes at a brain and behavioral level. Additionally, it is important to consider the impacts of chronic pain on decision-making across different populations, such as older adults with and without cognitive impairment or individuals with (or at risk of) substance use disorders. Further, as the subfield of chronic pain and decision-making continues to evolve, more rigorous approaches, such as systematic reviews or meta-analyses, will be needed to critically appraise the quality of current evidence and assess risk for bias.

Clinical implications.

Expanding investigations into different decision-making domains will be needed to better understand the relationship between chronic pain and decision-making, especially regarding decisions that matter in daily life. Medical decisions comprise one domain of high personal relevance for individuals with chronic pain. People with chronic pain often must navigate decisions regarding how to manage their pain. These decisions can be made independently or with the guidance of their medical team or the support of their loved ones (i.e., shared decision-making). Attitudes, beliefs, and motivations, including trust, adversity, self-efficacy, expectancies, and fear-avoidance, all play into decisions regarding pain management.

Examining potential cognitive barriers and facilitators during scenarios relating to medical decisions can be a fruitful direction for future work. For example, this review indicates that chronic pain increases risk-taking and delay discounting. This shift in preferences has implications for treatment recommendations, like increasing physical activity, which requires exerting effort for potentially delayed benefits, such as improved functionality and pain relief. Individuals with chronic pain who are more likely to avoid rather than confront their pain, or discount the value of delayed benefits, may struggle to adhere to physically and cognitively effortful treatments meant to reduce inactivity and disability in the long term. Additionally, due to increased tolerance for risk-taking and preference for immediate rewards, some with chronic pain may over-rely on medications, such as opioids, to alleviate pain in the short term at the risk of long-term consequences, including misuse and dependence. Research that seeks to characterize decision-making strategies and outcomes among individuals with chronic pain can help develop evidence-based interventions to enhance medical decisions (e.g., via cognitive-behavioral training or education). Future experimental investigations and therapeutic approaches can also incorporate neurocognitive tests and behavioral economic tasks, such as effort-based or dual-task paradigms, to assess how chronic pain affects cognitive load and decisions, such as those relating to physical movement ⁹¹. Integrating therapies that facilitate pain self-efficacy early in treatment may also modify medical decisions.

Another understudied decision-making domain that is relevant to people with chronic pain is social decision-making. Social relationships are dynamic and complex, especially when facing chronic illness. Individuals with chronic pain often experience limited social interaction and feelings of perceived injustice, which negatively impact quality of life ⁴⁴. Individuals with chronic pain may also withdraw from relationships and avoid social activities they used to enjoy due to motivational factors like pain-related avoidance ^9,92. Characterizing the psychosocial and motivational influences of social decision-making in chronic pain, as well as developing evidence-based tools that promote engagement, discernment, and trust with others, could produce significant benefits for individuals with chronic pain.

Adapting existing interventions can help target the cognitive and decision-making difficulties associated with chronic pain. Cognitive behavioral therapy for chronic pain (CBT-CP), for example, provides opportunities to apply coping, stress management, and mindfulness skills to combat pain-related distress⁹³. Other more novel therapies, such as cognitive remediation, which focuses on addressing cognitive deficits, could be combined with CBT-CP to support people with chronic pain experiencing cognitive difficulties⁹⁴. Future adaptations of these therapies can also address topics such as optimizing daily tasks, planning for the future (e.g., finances, advance care), detecting deception and fraud, maintaining and repairing relationships with others, and/or choosing well during emotionally charged situations. Integrating decision-making interventions adapted for chronic pain into digital and mobile health platforms can also make these interventions more accessible. This approach could also leverage ecological momentary assessments to capture present-moment behaviors and inform just-in-time interventions, which can personalize content and deliver tailored support when needed. Thus, more translational and applied research on potential interventions to assist with decision-making in chronic pain in the real world is a worthwhile pursuit.

VI. Conclusions

In conclusion, a synthesis of current evidence indicates that chronic pain alters decision-making via multiple paths, including 1) reduced decision performance, 2) increased risk-taking and delay discounting, 3) altered outcome sensitivity, and 4) reduced learning and cognitive flexibility. Work to date also demonstrates parallel changes to the brain and the moderating roles of individual factors, though current investigations on factors, such as age, are limited. More investigation is needed to understand the extent to which decision-making impairments are evident within and across specific chronic pain conditions and to parse out potential exacerbating factors. This narrative review represents an initial step in understanding the state of the subfield of chronic pain and decision-making, which will, in the future, include more representative samples, investigation on multiple domains of decision-making, theoretical development, systematic evaluations, and adapted interventions.

Highlights.

• Chronic pain is prevalent and costly, with significant impacts on cognition and behavior

• Chronic pain affects performance, delay discounting, outcome sensitivity, and learning

• Effects of chronic pain on decision-making vary by individual factors (e.g., age, sex/gender)

• The relationship between chronic pain and decision-making has implications for future work

• More theory-driven, representative investigations and evidence-based interventions are needed