Sei sulla pagina 1di 9

Neuroscience 161 (2009) 671– 679

COGNITIVE IMPAIRMENT OF PREFRONTAL-DEPENDENT DECISION-MAKING IN RATS AFTER THE ONSET OF CHRONIC PAIN

M. PAIS-VIEIRA, a,b M. M. MENDES-PINTO, b D. LIMA a,c AND V. GALHARDO a,b *

a Instituto de Histologia e Embriologia, Faculdade de Medicina do Porto, 4200-319 Porto, Portugal

b IBMC, Instituto de Biologia Molecular e Celular, Rua do Campo Alegre, 823, 4150-180 Porto, Portugal

c Laboratório de Biologia Celular e Molecular, Faculdade de Medicina do Porto, 4200-319 Porto, Portugal

Abstract—Forced choice between alternative options of un- predictable outcome is a complex task that requires contin- ual update of the value associated with each option. Prefron- tal areas such as the orbitofrontal cortex (OFC) have been shown to play a major role in performance on ambiguous decision-making tasks with substantial risk component, broadly named as “gambling tasks.” We have recently dem- onstrated that rats display complex decision-making behav- ior in a rodent gambling task based on serial choices be- tween rewards of different value and probability. This rodent task retains many of the key characteristics of the human Iowa Gambling Task (IGT), and performance in this novel task is also disrupted by OFC or amygdalar lesioning. In the present study we addressed if rat models of chronic pain would have impaired performance in this gambling task, since it is already known that the IGT response patterns of human pain patients are comparable to individuals with OFC lesions. We found that animals with a monoarthritic inflam- matory model of chronic pain systematically preferred the lever associated with larger but infrequent rewards. In addi- tion, we measured the neurochemical content of the OFC, amygdala and nucleus accumbens using HPLC, and found that in prolonged chronic pain animals there was a decrease in the tonic levels of dopamine, DOPAC (3,4-hydroxyphenyl- acetic acid) and 5-HIAA (5-hydroxyindole-3-acetic acid) in the OFC. This is the first report of the effect of chronic pain in rat decision-making processes and supports the notion that pain may have profound effects on the functioning of the reward- aversion circuitry relevant to strategic planning. © 2009 IBRO. Published by Elsevier Ltd. All rights reserved.

Key words: orbitofrontal cortex, uncertainty, monoarthritis, reward, gambling.

Chronic pain is a multidimensional experience that can lead to deficits in several cognitive abilities such as speed processing, memory and attention (see Hart, 2000 for review). Clinical studies have shown that chronic pain

*Correspondence to: V. Galhardo, IBMC, Instituto de Biologia Molec- ular e Celular, Rua do Campo Alegre, 823, 4150-180 Porto, Portugal. Tel: 351-22-6074900; fax: 351-22-6099157. E-mail address: galhardo@med.up.pt (V. Galhardo). Abbreviations: CFA, complete Freund’s adjuvant; DOPAC, 3,4-hy- droxyphenyl-acetic acid; IGT, Iowa Gambling Task; OFC, orbitofrontal cortex; RGT, rodent gambling task; 5-HIAA, 5-hydroxyindole-3-acetic acid.

patients present several psychological disturbances such as high levels of anxiety and depression (Henningsen and Lowe, 2006; Wood et al., 2007), stress ( Woolf, 1983; Chapman et al., 2008 ), or reduced sleep quality ( Kunder- mann et al., 2004). Moreover, important neural alterations were described in chronic pain patients such as a de- crease in grey matter density and tonic levels of neuro- transmitters in prefrontal areas ( Grachev et al., 2000; Ap- karian et al., 2004b). Prefrontal cortical regions are crucial for normal performance in many cognitive functions in both humans and animals, particularly in reward-related tasks that involve strategic planning and decision-making (Miller and Cohen, 2001; Wallis, 2007 ). Neurological patients with orbitofrontal or amygdalar lesions are impaired in gam- bling-like situations such as the Iowa Gambling Task (IGT) that require identification of advantageous decision-mak- ing strategies among options of uncertain outcome (Be- chara et al., 1994, 1997). The report that chronic pain patients are also impaired in the same gambling task ( Ap- karian et al., 2004a) , strengthened the suggestion that chronic pain by itself may lead to changes in the reward/ aversion system and that this can be on the basis of the co-morbid psychiatric disorders observed in chronic pain pa- tients (Borsook et al., 2007; Leknes and Tracey, 2008). How- ever, regardless of the importance that these cognitive defi- cits may have to the understanding of the pathophysiology of chronic pain, almost no studies exist on the cognitive impair- ments induced in animal models of chronic pain. We have recently developed a rodent gambling task (RGT) that retains the key features of the human gambling tasks and that like the IGT is sensitive to orbitofrontal lesioning ( Pais-Vieira et al., 2007 ). Therefore, in this study we applied this task to test the hypothesis that animals with inflammatory chronic pain would express behavioral pat- terns of preference for high risk choices when faced with a reward schedule of uncertain outcome. Moreover, since it has been suggested that impaired IGT performance may be linked to reduced levels of dopamine in the reward- aversion circuitry ( Sevy et al., 2006 ), we decided to verify if the induction of chronic pain would affect the tonic level of monoaminergic neurotransmitters in the orbitofrontal cortex (OFC) and two other connected areas, the amyg- dala and nucleus accumbens.

EXPERIMENTAL PROCEDURES

Sprague–Dawley male rats (5 days of sham: n 6; 5 days of pain,

n 6; 21 days of sham: n 5; 21 days of pain, n 4; 56 days of

sham: n 4; 56 days of pain, n 5) with weights between 300 and 320 g were used in all experiments (Charles-River, Barcelona, Spain). Animals received water ad libitum but were food deprived

0306-4522/09 $ - see front matter © 2009 IBRO. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.neuroscience.2009.04.011

671

672

M. Pais-Vieira et al. / Neuroscience 161 (2009) 671– 679

to 85% of age-matched body weight by limiting their access to food. All experiments were conducted in accordance with the local guidelines of the IBMC Committee for the Humane use of Animals, the European Communities Council Directive of November 24, 1986 (86/609/EEC), as well as with the guidelines of the Interna- tional Association for the Study of Pain on the use of awake animals ( Zimmermann, 1983 ). All efforts were taken to minimize the number of animals and their suffering.

Baseline anxiety

Naive levels of anxiety and exploratory behavior were initially mea- sured using the elevated plus maze test for rat (Pellow et al., 1985). Animals were rank-ordered according to their individual scores and gaussian distributed between control and experimen- tal groups in order to decrease the importance of individual differ- ences of basal anxiety in the experimental results of the decision- making task. This control step was introduced in the experimental design to minimize interindividual differences in pain perception, since our previous unpublished results suggested that baseline anxiety levels predict individual post-operative nociceptive re- sponses in the complete Freund’s adjuvant (CFA) model; a similar correlation between baseline anxiety and pain perception has also been shown for different mice strains ( Vatine et al., 2000 ). More- over, it has recently been reported in humans that trait anxiety is associated with both impaired decision making and increased anticipatory physiological responses to advantageous trials in the IGT ( Miu et al., 2008 ).

Chronic pain model

Persistent monoarthritic inflammatory pain was induced by injecting CFA in the tibiotarsal joint of the left hind paw (Butler et al., 1992). CFA was prepared by mixing 60 mg of desiccated Mycobacterium butyricum (Difco Laboratories, Becton Dickinson, NJ, USA) to paraf- fin oil (6 ml), saline (4 ml) and Tween 80 (1 ml), and injected under brief halothane anesthesia. In sham animals a needle was intro- duced in the hind paw soft tissue under anesthesia. Sensory threshold for noxious stimulation was measured us- ing von Frey filaments (Somedic, Sweden) as previously de- scribed (Chaplan et al., 1994 ).

Behavioral protocol

The RGT of decision under ambiguity has been described in further detail in a previous paper ( Pais-Vieira et al., 2007 ). It consists in an octogonal hub (Coulbourn Instruments, Allentown, PA, USA) partially divided into two adjacent chambers by a 15 cm protruding opaque Plexiglas panel. Each half of the hub contained one non-retractable lever and one food cup connected to an automated pellet dispenser (Coulbourn Instruments). Video-track- ing of movement and control of feeders and levers was done using OpenControl ( Aguiar et al., 2007 ). Following a brief tone the animal entered the hub and had to choose between the left and right side of the hub and press the respective lever to receive a food reward (45 mg chocolate flavor sucrose pellets, Research Diets Inc., New Brunswick, NJ, USA). After receiving the reward, the animals were placed back in the entrance chamber and had to wait 5 s for the start of the following trial. After auto-shaping lever press training criteria was accom- plished, the animals had six sessions (one session per day, with a random duration of 60 –120 trials), of the non-gambling phase in which both levers had the same associated reward of one food pellet per trial. However, rewards were given only in eight out of every 10 trials regardless of the hub side chosen by the animal. After these six sessions, animals were CFA-injected or sham manipulated and resumed the behavioral protocol for another four sessions; the animals of the long-term experimental groups of 21 and 56 days of inflammatory pain, were also retrained in the 4

days preceding the gambling-task. At the 5th, 21st or 56th day post-injection animals were tested at the gambling-task: a single probe session of 90 trials in which the levers now corresponded to food rewards of distinct value and probability: one lever remained as in the non-gambling phase (low risk lever, since it returned one food pellet in every eight out of 10 visits), while the other returned

three food pellets, but only in three out of every 10 visits— high risk lever. Hub side allocation of levers was counterbalanced between animals in each group. Note that the terms high and low risk associated with each lever relate only to the instantaneous prob- ability of occurrence of a rewarding event and do not relate with its long-term net gain—in fact the high risk lever would dispense more pellets if it were persistently chosen. Results of the behavioral task were taken from the analysis of the individual patterns of choice during the gambling task (probe session). Five parameters were calculated for each animal: Pref- erence Index, Final Preference, Lever Persistence, Incomplete Trials, and Total Gain. The Preference Index was defined as the proportion of choices between both levers and calculated for each 10 consecutive trials as in the IGT: (low risk lever choices)–(high risk lever choices)/number of completed trials. Hence, the Prefer- ence Index resulted in a sequence of nine values ranging from 1

to 1 whether the animal always preferred the high risk reward or

the low risk lever, respectively. Final Preference was defined as

the preference index for the final 30 trials (trials 61–90) of the probe session. Lever Persistence during the probe session was defined as the number of times the chosen lever was the same as

in the previous trial, referenced to the outcome of previous trial.

Values of Lever Persistence were calculated in groups of 15 consecutive trials for each reward condition. Incomplete Trials were those in which the 20 s trial limit was reached without the animal pressing any of the levers. Total Gain was considered to be the number of pellets obtained during the probe session.

HPLC tissue analysis

Neurochemical analysis of the tonic content of monoamines and monoamine metabolites in forebrain areas was performed in con- trols ( n 10) and in animals with 5 ( n 4), 21 ( n 6) or 56 ( n 4) days of pain, that were not subjected to the RGT. Electrochemical detection of dopamine, 3,4-hydroxyphenyl-acetic acid (DOPAC), 5-HT, 5-hydroxyindole-3-acetic acid (5-HIAA), norepinephrine and epinephrine in reversed-phase HPLC was applied according to a modified method of Ali et al. (1993) . The animals were decapitated with a small animal guillotine and specific regions of brain tissue were desiccated, frozen in 2-methyl butane over dried ice and stored at 80 °C. Before HPLC analysis, samples were left overnight with 200 L of per- chloric acid 0.2 N at 20 °C. The homogenate was centrifuged (5000 rpm, 3 min) and the supernatant filtered through a 0.2 m Nylon microfilter (COSTAR) by centrifugation (10,000 rpm, 5 min) for HPLC analysis. The resulting pellet was kept at 20 °C until protein quantification. Analyses were carried out in a Gilson Medical Eletronics HPLC system (Middleton, WI, USA) with an LC234 auto-injector, equipped with an LC307 delivery pump and with an LC142 elec- trochemical detector, under reversed phase conditions with a Supelcosil LC 7.5 4.6 cm, 3 m column. The software used was

a 712 HPLC system controller data version 1.30. Compounds

were eluted isocratically over 18 min run time at a flow rate of 1 mL/min. The mobile phase consisted of 70 mM potassium dihy- drogen phosphate buffer (pH adjusted to 3.0 with phosphoric acid), 1 mM 1-hepatosulfonic acid, 107.5 M sodium EDTA and 10% methanol. Sample injection was 20 L and the electrochem- ical detection was recorded with a glassy carbon working elec- trode set at 0.75 V. Identification was performed by comparison with standard retention times determined by injections of standard mixture run at given intervals between sample analysis. Quantifi- cation was made using the calibration curve standards and with

M. Pais-Vieira et al. / Neuroscience 161 (2009) 671– 679

673

Pais-Vieira et al. / Neuroscience 161 (2009) 671– 679 673 Fig. 1. Preference index of choices

Fig. 1. Preference index of choices between two levers throughout the probe session of the gambling phase of the task. All experimental groups show a typical profile: during the first 30 trials of the session both controls and inflammatory chronic pain animals present similar results but as the session progresses the groups drift in their preferences with control groups shifting their preference to the low risk lever. Positive values of Preference indicate larger number of choices of the low risk, low-reward lever, and negative values indicate preference for the high risk, high-reward, lever. Values of Preference are calculated for each group of 10 consecutive trials.

the protein content. Amounts of each compound are expressed in ng of catecholamine per mg of protein. The r-values of each catechol- amine were the following: dopamine 0.9998, DOPAC 0.9999, 5-HT 0.9998, 5-HIAA 0.9998, norepinephrine 0.9994, and epi- nephrine 0.9998. Protein content was determined by the Bradford Bio-Rad protein assay reagent using BSA as a standard and a Sunrise Absorbance Microplate Reader (Tecan). To enhance the protein extractability, pellets in phosphate buffer were previously sonicated in ice for 14 s with an ultrasonic homogenizer (Sonoplus HD 2200) adjusted to 40% pulse/second, with a minimum output of

10%).

HPLC grade methanol was purchased from Panreac. 2-Methyl butane and hepatosulfonic acid were obtained from Fluka. Perchloric acid, sodium EDTA, potassium dihydrogen phosphate, sodium dihydrogen phosphate monohydrate and di- sodium hydrogen phosphate dihydrate were all from Merck, and phosphoric acid from Aldrich. Bio-Rad protein assay from Bio- Rad. Ultrapure water (18.2 M /cm) (Maxima ultra pure water) was used for all the analysis. Bovine serum albumin and commercial standards of dopamine (3,4-hydroxyphenethylamine), DOPAC, 5-HT, 5-HIAA, (–)-norepinephrine (NE), and (–)-epinephrine (E), were purchased from Sigma.

RESULTS

Mechanical threshold for noxious stimulation was signifi-

cantly decreased in the chronic pain animals used in all experiments (CFA 5 days: 0.03 0.01 g; sham 5 days:

11.58 2.47 g, Mann–Whitney U 0.0, P 0.01; CFA 21

days: 0.06 0.01 g; sham 21 days: 16.32 3.52 g, Mann– Whitney U 0.0, P 0.01; CFA 56 days: 0.06 0.01 g; sham 56 days: 8.87 2.81 g, Mann–Whitney U 0.0,

P 0.05). No animals were excluded from the study due to

extreme values of baseline anxiety in the elevated plus maze, and the experimental groups had similar distribu- tions: animals to include in pain groups: 43.58 8.16; ani- mals to include in sham groups: 52.29 8.99, P 0.05. Left/right levels of individual choice during the non- gambling phase of the task showed no specific preference for one side of the arena (ratio of left/right choices as measured by the Preference Index of the last session of 60

trials before the probe session was CFA 5 days:

0.11 0.01, sham 5 days: 0.11 0.05, t 9 0.099, P 0.9; CFA 21 days: 0.08 0.06, sham 21 days: 0.02 0.06, t 7 0.68, P 0.5; CFA 56 days: 0.002 0.03, sham 56 days: 0.01 0.06, t 7 0.14, P 0.8). Since during the probe session the distinct reward probabilities (P 0.8 of one pellet versus P 0.3 of three pellets) would result in different cumulative net gains if only one lever were persistently chosen, we preliminarily checked during the non-gambling phase if the animals were able to detect the long term advantage of the high risk lever; for this we set the probability of one lever at 0.8 and the other at 0.9 with both levers dispensing only one pellet, and performed a session of 90 trials. The comparison of the number of choices for the two levers showed no side preference (n 4; Preference Index 0.03 0.03; lever with 0.9 probability 4.833 0.1667; lever with 0.8 proba- bility 5.167 0.1667; t 23 1.00; P 0.3).

Preference index analysis

Five days after CFA injection. The Preference Index of the probe session resulted in a characteristic pattern with chronic pain animals obtaining negative values (i.e. preferring the high risk lever over the low risk; Fig. 1). Final Preference in the last 30 trials of the probe session showed significant differences between chronic pain and the respective control groups (CFA: 0.41 0.13, sham: 0.33 0.12, t 10 4.26, P 0.005). The Total Gain number of pellets achieved by sham and pain animals was not different between groups (CFA: 69.8 3.6, sham: 73.3 1.6; Mann–Whitney U 16.00, P 0.5). Pain animals presented a higher number of incom- plete trials during the probe session (CFA: 8.8 4.0; sham:

1.2 0.4 incomplete trials; Mann–Whitney U 1.5, P 0.01). In order to test if the higher number of incomplete trails of the chronic pain animals was due to impaired movement or pellet satiation, 1 day after the probe session the CFA and sham animals were run in a longer session of 150 trials, in which

674

M. Pais-Vieira et al. / Neuroscience 161 (2009) 671– 679

both levers were set to give one pellet in every trial. In these conditions there was no evident sign of impaired movement or satiation, and there was no difference of incomplete trials between groups (CFA: 2.2 0.8; sham: 2.0 0.4; Mann–Whit- ney U 17.0, P 0.9).

Twenty-one days after CFA injection. The behavioral pattern of the Preference Index was similar to the experi- ment performed after 5 days of chronic pain, with mono-

arthritic animals repeatedly preferring the high risk lever

( Fig. 1 B). The Final Preference shows that control animals developed preference for low risk choices, while monoar- thritic animals developed preference for high risk choices (CFA: 0.42 0.20; sham 21 days, 0.33 0.13; t 7 3.28, P 0.05). No difference was found between groups in the Total Gain number of pellets rewarded during the probe session (CFA: 77.25 0.25, sham 21 days: 76.40 1.21, Mann–Whitney U 9.00, P 0.90). The number of Incom- plete Trials was also not different between the two groups (CFA 21 days: 1.00 1.0, sham 21 days: 0.20 0.20, Man- n–Whitney U 9.00, P 0.90).

Fifty-six days after CFA injection. The behavioral pat- tern of the Preference Index was similar to both the 5 and 21 days of chronic pain experiments, with monoarthritic animals preferring high risk choices (Fig. 1C). The Final Preference confirms this pattern of choices (CFA 56 days: 0.35 0.06, sham 56 days: 0.40 0.11, t 7 6.02, P 0.001). No differ- ences were found between groups in the Total Gain number of pellets rewarded during the probe session (CFA 56 days:

78.40 0.51, sham 56 days: 77.0 0.71, Mann–Whitney U 4.5, P 0.10). The number of Incomplete Trials was also not different between the two groups (CFA 56 days: 0.2 0.2, sham 56 days: 2.5 1.9, Mann–Whitney U 6.0, P 0.4).

Persistence analysis

Since the preference analysis showed that regardless of the time from CFA injection the patterns of preference were similar for all groups, we performed the analysis of Persistence using pooled data from all sham and CFA animals (Fig. 2 ); additionally we also analyzed separately the data for each experimental time group. We do not present graphically the separate analysis since it followed the same general trend as in the pooled data (see below).

Pooled data. In the pooled data there was a significant Group effect and Interaction after rewarded trials in the high risk lever (Fig. 2A—Group: F 1,140 17.17, P 0.001; Time:

F 5,140 0.51, P 0.7; Interaction: F 5,140 3.10, P 0.05), and a significant Group effect and Interaction after non-rewarded trials in the high risk lever (Fig. 2D—Group: F 1,140 12.73, P 0.01; Time: F 5,140 1.85, P 0.1; Interaction: F 5,140 6.03, P 0.0001). There was a Group effect and Interaction after rewarded trials in the low risk lever (Fig. 2C—Group:

F 1,140 28.48, P 0.0001; Time: F 5,140 0.74, P 0.5; Inter- action: F 5,140 2.62, P 0.05), and a significant Group effect after non-rewarded trials in the low risk lever (Fig. 2D— Group: F 1,140 29.56, P 0.0001; Time: F 5,140 2.08, P 0.05; Interaction: F 5,140 1.75, P 0.1).

Five days after CFA injection. The analysis of Persis- tence revealed a Group effect and Interaction after rewarded trials in the low risk lever (Group: F 1,45 65.75, P 0.0001; Time: F 5,45 2.14, P 0.05; Interaction: F 5,45 3.70, P 0.01). After low risk non-rewarded choices we found a significant Group effect (Group: F 1,45 6.78, P 0.05; Time: F 5,45 0.54, P 0.75; Interaction: F 5,45 1.93, P 0.1). Persistence after rewarded high risk choices revealed no significant differ- ences (Group: F 1,45 1.20, P 0.1; Time: F 5,45 1.73, P 0.3; Interaction: F 5,45 1.27, P 0.2), while persistence after non- rewarded high risk choices showed a significant Group effect and Interaction (Group: F 1,45 7.35, P 0.05; Time:

F 5,45 0.48, P 0.7; Interaction: F 5,45 3.28, P 0.05).

Twenty-one days after CFA injection. Comparison of Persistence values after low risk rewarded choices showed a significant Group effect (Group: F 1,35 5.53, P 0.05; Time:

F 5,35 0.33, P 0.8; Interaction: F 5,35 0.44, P 0.8). After low risk non-rewarded choices Group and Interaction were found to be significant (Group: F 1,35 12.61, P 0.01; Time:

F 5,35 1.78, P 0.1; Interaction: F 5,35 5.05; P 0.01). After high risk rewarded choices no significant effects were found (Group: F 1,35 0.84, P 0.4; Time: F 5,35 0.34, P 0.8; Inter- action: F 5,35 1.55, P 0.2). Also after high risk non-rewarded choices no significant effects were found (Group: F 1,35 5.01, P 0.05; Time: F 5,35 2.00, P 0.1; Interaction: F 5,35 1.40, P 0.2).

Fifty-six days after CFA injection. Values of Persis- tence after low risk rewarded choices showed a significant Group effect (Group: F 1,35 5.80, P 0.05; Time: F 5,35 0.99, P 0.44; Interaction: F 5,35 0.48, P 0.7). After low risk non- rewarded choices a Group effect was found (Group:

F 1,35 19.73, P 0.01; Time: F 5,35 1.98, P 0.1; Interaction:

F 5,35 0.80, P 0.5). After high risk rewarded choices a Group effect was found (Group: F 1,35 15.63, P 0.01; Time:

F 5,35 0.44, P 0.8; Interaction: F 5,35 2.27, P 0.05). After high risk non-rewarded choices a Group effect and Interac- tion were also found (Group: F 1,35 6.82, P 0.05; Time:

F 5,35 0.50, P 0.7; Interaction: F 5,35 3.25, P 0.05).

HPLC analysis of tonic levels of monoamines

We performed an HPLC analysis of tonic levels of mono- amines and their metabolites in the OFC, amygdala, and nucleus accumbens tissues of controls and animals with 5, 21, and 56 days of chronic pain (see Table 1 for detailed results). Briefly, the results show that pain induced a de- crease in the levels of dopamine, DOPAC and 5-HIAA at the OFC in the 21 day time point (dopamine , Kruskal– Wallis statistic 9.13, P 0.05, Dunn’s multiple post hoc:

control vs. 21 days, difference in rank sum 9.39, P 0.05; DOPAC , Kruskal–Wallis statistic 11.99, P 0.01, Dunn’s multiple post hoc: control vs. 21 days, difference in rank sum 11.22, P 0.01; 5-HIAA , Kruskal–Wallis statis- tic 10.04, P 0.05, Dunn’s multiple post hoc: control vs. 21 days, difference in rank sum 8.66, P 0.05), but no other significant changes either in amygdala or nucleus accumbens.

M. Pais-Vieira et al. / Neuroscience 161 (2009) 671– 679

675

Pais-Vieira et al. / Neuroscience 161 (2009) 671– 679 675 Fig. 2. Persistence Index during the

Fig. 2. Persistence Index during the probe session of the gambling phase of the task. The figure shows the ratio of returns to the same lever in the

following trial for each output condition (A–D). Note that in the first trials the highest rate of return occurs for both groups at the high-reward lever, after

a rewarded trial; as the probe session progresses the animals persist on their preferred lever irrespective of having received or not received a reward

in the preceding visit to that lever.

DISCUSSION

This study shows that in a task sensitive to OFC impair- ment, the induction of chronic pain in rodents leads to a risk-prone pattern of choices favoring immediate larger gains. This is the first demonstration that chronic pain alters the neural mechanisms of decision-making in ro- dents. Moreover, we extend the significance of this perfor- mance impairment by showing that the induction of pro- longed pain reduces the dopamine, DOPAC and 5-HIAA tonic levels of the OFC in rodents. These results are in strong agreement with previous data from human patients showing that severe chronic pain disrupts performance in

OFC dependent tasks like the IGT ( Apkarian et al., 2004a) or the Object Alternation Task ( Mongini et al., 2005 ), and sheds lights on the mechanisms underlying the altered brain activity that is observed in chronic pain sufferers

( Baliki et al., 2008 ).

It should be noted that although the RGT mimics sev-

eral of the main characteristics of the IGT in particular the uncertainty about all outcome probabilities, there is one difference between the tasks: the IGT uses punishments (in the form of money loss) while in the RGT we use only absence of food rewards as “punishment.” One other form of implementation of the IGT for rodents ( Homberg et al.,

2008 ) used quinine-dipped food pellets as punishment for

certain choices. We preferred however to favor uncertainty about rewards rather than enhancing the component of aversive-learning in our task protocol. The effect of food punishments in the RGT is something to be addressed in future studies. Interestingly, and contrary to our initial ex- pectations, the Persistence analysis of our present data suggests that receiving a reward or not does not have a large effect on the decision between returning or not to the same lever in the immediately following trial, and that this

676

M. Pais-Vieira et al. / Neuroscience 161 (2009) 671– 679

Table 1. HPLC determination of tonic levels of monoamines in tissue

 

OFC

Amygdala

 

Nucleus accumbens

 

Dopamine

Control

n 9

19.37

4.64

n 9 n 4

19.73 5.28 17.77 3.95 24.52 6.25 27.37 9.36

n 8

948.60

229.40

5 Days

n 4

19.94 7.13 5.69 0.71 10.56 2.26

n

4

583.60

168.00

21 Days

n

6

n

6

n 6 n 4

1072.00

149.80

56 Days

n 4

n 4

473.10 185.80

DOPAC

Control

n

9

20.88

4.43

n

9

7.92 1.37

n 9 n 4

451.60 86.29 379.80 129.10 362.30 37.33 378.20 142.30

5 Days

n

4

18.80

4.55

n

4

9.26 1.91

21 Days

n

6

5.50 0.77

n 6

8.03

1.46

n 7

56 Days

n

4

10.55

1.64

n

4

13.60 1.96

n

4

5-HT

Control

5 Days

n 8 n 4

61.73

116.30

12.63

40.62

n 4

n

9

102.20

24.46

76.11 24.85

n 9 n 4

 

107.30

83.71

20.17

27.39

21 Days

n 6

44.90 4.09

n 6

79.25 17.75

n

6

135.30

19.35

56 Days

n

4

50.88 12.58

n

4

119.30

47.84

n 4

 

43.10 22.28

5-HIAA

Control

n 9

62.03

14.1

n

9

103.40

22.30

n

10

34.13 6.26

5 Days

n 4

76.70 25.24

n

4

130.70

50.65

n

4

49.05

7.06

21 Days

n 6

24.85 4.70

n 6

 

90.18 18.84

n 7

26.10

2.18

56 Days

n

4

37.50

1.94

n 4

158.80

42.10

n

4

38.11

7.96

Epinephrine

Control

n 4

97.75

48.68

n 4

46.49 23.40

n 4

 

38.11 9.48

5 Days

n 4

137.30

76.67

n

4

60.24 33.52

n 4

32.93 4.11

56 Days

n 4

36.43 7.94

n

4

82.12 27.69

n

4

31.48

7.78

Norepinephrine

Control

n

4

190.20

46.01

n 4

158.20

41.56

n 4

 

363.00

147.30

5 Days

n 4

249.40

67.69

n

4

156.00 44.52

n

4

397.70

80.70

56 Days

n 4

131.60 4.24

n 4

249.60 89.43

n 4

 

196.80 51.45

Values followed by * and ** represent significant differences between control and specific group for post hoc analysis with Dunn’s multiple comparison test respectively for P 0.05 and P 0.01.

effect becomes even smaller as the probe session progresses. For example, the probability of returning to the high risk lever in the 45–90 trials ( Fig. 2 A vs. Fig. 2 B) is about the same for each group regardless of having re- ceived a reward or not. This suggests that preference rather than impulsiveness is a key component in the RGT, and that somehow in control animals the loss aversion effect provided the low risk lever overrides the appeal of the larger but infrequent rewards of the high risk lever. This animal behavior is in accordance with the known effect that losses and gains are not valued equally and that loss aversion commonly drives decision-making (Tversky and Kahneman, 1981; Sokol-Hessner et al., 2009). Performance in decision-making under uncertainty in humans is particularly sensitive to orbitofrontal or amyg- dalar impairment either through permanent lesion or tem- porary disruption (Knoch et al., 2006 ), but the role played by these two areas on pain processing is somehow difficult to interpret. Acute nociceptive stimulation results in bilat- eral activation of OFC ( Hsieh et al., 1995; Rolls et al., 2003 ), and this activation is strongly modulated by the conscious expectation about the intensity of the impending painful stimulation ( Porro et al., 2002; Valet et al., 2004 ). In rodents, activation of OFC neurons increases the activity of subcortical antinociceptive areas of the descending modulatory pain control system such as the rostral ventro- medial medulla and the periaqueductal gray matter (Zhang

et al., 1997; Huang et al., 2001 ). However, ablation or blocking of OFC leads only to a transient attenuation of acute and chronic pain responses ( Baliki et al., 2003 ), raising the idea that although OFC activation plays a role in pain modulation, it is not directly involved in the mechanisms of pain perception. On the other hand, acute and chronic nociceptive stimulation decreases amygdalar activity ( Hsieh et al., 1995; Buchel et al., 1999; Petrovic et al., 2000 ) and animal studies have shown that amygdalar neurons present synaptic poten- tiation following both acute and chronic pain conditions ( Neugebauer et al., 2003; Han et al., 2004; Ikeda et al., 2007 ), leading to increased pain behavior ( Carrasquillo and Gereau, 2007; Fu et al., 2008 ). Blockade or ablation of amygdala reduces the antinociceptive power of sys- temic administration of morphine or cannabinoids ( Man- ning and Mayer, 1995; Manning et al., 2003 ). However, in contrast with OFC, amygdala inactivation has almost no effect on acute pain thresholds but only in the ex- pression of pain-related contextual memories suggest- ing an important role of the amygdala in anxiety-medi- ated pain ( Tanimoto et al., 2003; Gao et al., 2004 ). Several lines of evidence have shown the importance that reward circuits play in the processing of pain stimuli ( Borsook et al., 2007; Becerra et al., 2008). Not only chronic pain conditions are often accompanied with alter- ations in mood such as major depression and anxiety, but

M. Pais-Vieira et al. / Neuroscience 161 (2009) 671– 679

677

the pharmacological treatment of the mood conditions also leads to alleviation of the painful physical complaints (Fish- bain, 2002 ). Interaction between the limbic and somato- sensory systems is certainly not unexpected given the unpleasant nature of chronic pain, but only recently it has drawn the attention for more systematic studies, namely using imaging methodologies (Ploghaus et al., 2003; Bor- sook et al., 2007 ). It is commonly assumed that the role of disability introduced by chronic pain in the social structure

of the patients is crucial for the depressive conditions that

are co-morbid to severe pain conditions ( Dersh et al., 2002; Raichle et al., 2007 ). However, these mood disor- ders may instead reflect a more mechanistic alteration in the brain reward circuitry induced by the allostatic load of prolonged aversive stimulation ( Chapman et al., 2008 ). Interestingly, severe stress conditions that would similarly

recruit the aversion circuitry also lead to reduced prefrontal dopaminergic levels ( Mizoguchi et al., 2000 ). These neu- rochemical results agree with imaging data showing that chronic pain patients have tonic frontal hypoactivity ( Ap- karian et al., 2004b; Gundel et al., 2008 ) and reduced levels of excitatory neurotransmitters ( Grachev et al., 2000 ). Our present results demonstrating both a cognitive impairment and a reduction in the OFC dopaminergic con- tent, suggest that this dopamine loss is indicative of OFC decreased activity. In fact, dopamine depletion in the OFC

in rats, as well as lesions of this area, has been previously

associated with changes in the sensitivity to reward size in non-gambling ( Mobini et al., 2002; Kheramin et al., 2004) and gambling tasks ( Pais-Vieira et al., 2007 ). And the influence of orbitofrontal dopamine on the individual re- sponse to rewards is also strongly supported by the recent reports that individuals carrying a polymorphism of the prefrontal abundant dopamine catabolic enzyme COMT, that renders the enzyme more effective and therefore leads to reduced dopaminergic levels, have poor perfor- mances in the IGT ( Roussos et al., 2008 ) and present distinct patterns of brain activation to rewards (Dreher et al., 2009 ). Our present data do not unequivocally demonstrate that disruption of monoamine levels in OFC is the reason for the performance impairment in the RGT, since there is

a temporal mismatch between performance disruption

(that occurs in all time points tested) and the onset of the

neurochemical changes observed in the OFC (that is sig- nificant only at the 21 days after pain). One possibility is that the RGT would be highly sensitive to OFC activity so that slight individual changes in the local tonic level of neurotransmitters, undetected at the group analysis, would be sufficient to alter the performance; alternatively, the neurochemical changes may be a pain-induced alteration entirely unrelated with the RGT performance. Anyway, it should be noted here that there was a large interindividual difference in the tonic values of monoamines in all regions studied that may have precluded the finding of statistical differences. In any case, the absence of pain-induced differences in monoaminergic tonic levels at the amygdala and nucleus accumbens does not rule out the possibility that these

areas may also present altered activity contributing to the distinct performance in the RGT. Indeed, we have prelim- inary results suggesting that modulation of amygdala ac- tivity reverses the high risk pattern of choices of pain animals (Neugebauer et al., 2007 ). On the other hand, the neural processing of ambiguous decision-making involving unequally sized rewards is known to activate nucleus ac- cumbens in both animals ( Carelli and Deadwyler, 1997 ) and humans ( Knutson et al., 2001), and this area is cer- tainly expected to be particularly active in the RGT. Inter- estingly it was recently shown that the expectation-driven dopamine release in the nucleus accumbens correlates not only with the individual range of response to monetary rewards but also with the individual range of placebo- induced analgesia ( Scott et al., 2007 ). Moreover, the ven- tral striatum is repeatedly reported to present morphomet- ric changes in pain patients (Schmidt-Wilcke et al., 2007; Geha et al., 2008 ). The involvement of the nucleus accum- bens in the pain-induced impairment at the RGT is cer- tainly a topic that merits further study. The still sparse literature on monoamine modulation of pain does not elucidate the possible roles played by spe- cific forebrain areas since it commonly stems from ob- served effects of systemic drug administration. For exam- ple, knockout animals for dopamine and 5-HT receptors are known to have altered nociceptive perception (Man- sikka et al., 2005; Kayser et al., 2007 ) while dopamine and 5-HT reuptake inhibitors have analgesic efficacy (Sindrup et al., 2005; Wernicke et al., 2006; Sultan et al., 2008; Hauser et al., 2009 ); some pain syndromes are character- ized by reduction of monoaminergic receptors and trans- porters ( Yamamoto et al., 2004; Kupers et al., 2009) or impaired dopaminergic responses to painful stimuli (Wood et al., 2007 ). Moreover, the forebrain role that monoamines might play in the modulation of somatosensory perception is often overlooked when compared with the well known and important role that monoamines, especially 5-HT, have in medulla-mediated inhibition of nociceptive spinal circuits ( Millan, 2002 ). However, recent human data have highlighted the importance of the activity of forebrain reward circuits in the shaping of individual responses to chronic pain ( Ap- karian, 2008 ). Our present data support the notion that prolonged pain conditions may have profound effects on the functioning of the reward–aversion circuitry, result- ing in alterations of the neural mechanisms relevant to strategic planning.

Acknowledgments—The authors wish to thank the Neurobehavior Unit at IBMC (Teresa Summavielle and Juliana Alves) for the use of HPLC equipment in the experiments described in this study. Their helpful expertise in HPLC monoamine quantification was invaluable for these experiments. The authors are also indebted to Clara Monteiro for her help in the HPLC assays, Paulo Aguiar and Luis Mendonça for their help in the automation of the behavioral arenas. Funding for these studies was provided by grants POCI/ SAU-NEU/63034/2004, SFRH/BD/24383/2005, and BIAL Foun- dation 84/04.

678

M. Pais-Vieira et al. / Neuroscience 161 (2009) 671– 679

REFERENCES

Aguiar P, Mendonca L, Galhardo V (2007) OpenControl: a free open source software for video tracking and automated control of be- havioral mazes. J Neurosci Methods 166:66 –72. Ali SF, David SN, Newport GD (1993) Age-related susceptibility to MPTP-induced neurotoxicity in mice. Neurotoxicology 14:29 –34. Apkarian AV (2008) Pain perception in relation to emotional learning. Curr Opin Neurobiol 18:464 – 468. Apkarian AV, Sosa Y, Krauss BR, Thomas PS, Fredrickson BE, Levy R, Harden RN, Chialvo DR (2004a) Chronic pain patients are im- paired on an emotional decision-making task. Pain 108:129–136. Apkarian AV, Sosa Y, Sonty S, Levy RM, Harden RN, Parrish TB, Gitelman DR (2004b) Chronic back pain is associated with de- creased prefrontal and thalamic gray matter density. J Neurosci 24:10410 –10415. Baliki M, Al-Amin HA, Atweh SF, Jaber M, Hawwa N, Jabbur SJ, Apkarian AV, Saade NE (2003) Attenuation of neuropathic mani-

festations by local block of the activities of the ventrolateral orbito- frontal area in the rat. Neuroscience 120:1093–1104. Baliki MN, Geha PY, Apkarian AV, Chialvo DR (2008) Beyond feeling:

chronic pain hurts the brain, disrupting the default-mode network dynamics. J Neurosci 28:1398 –1403. Becerra L, Harris W, Joseph D, Huppert T, Boas DA, Borsook D (2008) Diffuse optical tomography of pain and tactile stimulation: activa- tion in cortical sensory and emotional systems. Neuroimage

41:252–259.

Bechara A, Damasio AR, Damasio H, Anderson SW (1994) Insensi- tivity to future consequences following damage to human prefron- tal cortex. Cognition 50:7–15. Bechara A, Damasio H, Tranel D, Damasio AR (1997) Deciding ad- vantageously before knowing the advantageous strategy. Science

275:1293–1295.

Borsook D, Becerra L, Carlezon WA Jr, Shaw M, Renshaw P, Elman

I, Levine J (2007) Reward-aversion circuitry in analgesia and pain:

implications for psychiatric disorders. Eur J Pain 11:7–20. Buchel C, Dolan RJ, Armony JL, Friston KJ (1999) Amygdala-hip- pocampal involvement in human aversive trace conditioning re- vealed through event-related functional magnetic resonance imag- ing. J Neurosci 19:10869 –10876. Butler SH, Godefroy F, Besson JM, Weil-Fugazza J (1992) A limited arthritic model for chronic pain studies in the rat. Pain 48:73– 81. Carelli RM, Deadwyler SA (1997) Cellular mechanisms underlying reinforcement-related processing in the nucleus accumbens: elec- trophysiological studies in behaving animals. Pharmacol Biochem Behav 57:495–504.

Carrasquillo Y, Gereau RW (2007) Activation of the extracellular sig- nal-regulated kinase in the amygdala modulates pain perception.

J Neurosci 27:1543–1551.

Chaplan SR, Bach FW, Pogrel JW, Chung JM, Yaksh TL (1994) Quantitative assessment of tactile allodynia in the rat paw. J Neu- rosci Methods 53:55– 63. Chapman CR, Tuckett RP, Song CW (2008) Pain and stress in a systems perspective: reciprocal neural, endocrine, and immune interactions. J Pain 9:122–145. Dersh J, Polatin PB, Gatchel RJ (2002) Chronic pain and psychopa- thology: research findings and theoretical considerations. Psycho- som Med 64:773–786. Dreher JC, Kohn P, Kolachana B, Weinberger DR, Berman KF (2009) Variation in dopamine genes influences responsivity of the human reward system. Proc Natl Acad Sc iUSA 106:617– 622. Fishbain DA (2002) The pain-depression relationship. Psychosomat- ics 43:341–342. Fu Y, Han J, Ishola T, Scerbo M, Adwanikar H, Ramsey C, Neuge- bauer V (2008) PKA and ERK, but not PKC, in the amygdala contribute to pain-related synaptic plasticity and behavior. Mol Pain

4:26.

Gao YJ, Ren WH, Zhang YQ, Zhao ZQ (2004) Contributions of the anterior cingulate cortex and amygdala to pain- and fear-condi- tioned place avoidance in rats. Pain 110:343–353. Geha PY, Baliki MN, Harden RN, Bauer WR, Parrish TB, Apkarian AV (2008) The brain in chronic CRPS pain: abnormal gray-white mat- ter interactions in emotional and autonomic regions. Neuron 60:570 –581. Grachev ID, Fredrickson BE, Apkarian AV (2000) Abnormal brain chemistry in chronic back pain: an in vivo proton magnetic reso- nance spectroscopy study. Pain 89:7–18. Gundel H, Valet M, Sorg C, Huber D, Zimmer C, Sprenger T, Tolle TR (2008) Altered cerebral response to noxious heat stimulation in patients with somatoform pain disorder. Pain 137:413– 421. Han JS, Bird GC, Neugebauer V (2004) Enhanced group III mGluR- mediated inhibition of pain-related synaptic plasticity in the amyg- dala. Neuropharmacology 46:918 –926. Hauser W, Bernardy K, Uceyler N, Sommer C (2009) Treatment of fibromyalgia syndrome with antidepressants: a meta-analysis. JAMA 301:198 –209. Henningsen P, Lowe B (2006) Depression, pain, and somatoform disorders. Curr Opin Psychiatry 19:19 –24. Homberg JR, van den Bos R, den Heijer E, Suer R, Cuppen E (2008) Serotonin transporter dosage modulates long-term decision-mak- ing in rat and human. Neuropharmacol 55:80 – 84. Hsieh J-C, Belfrage M, Stone-Elander S, Hansson P, Ingvar M (1995) Central representation of chronic ongoing neuropathic pain studied by positron emission tomography. Pain 63:225–236. Huang X, Tang JS, Yuan B, Jia H (2001) Morphine applied to the ventrolateral orbital cortex produces a naloxone-reversible antino- ciception in the rat. Neurosci Lett 299:189 –192. Ikeda R, Takahashi Y, Inoue K, Kato F (2007) NMDA receptor-inde- pendent synaptic plasticity in the central amygdala in the rat model of neuropathic pain. Pain 127:161–172. Kayser V, Elfassi IE, Aubel B, Melfort M, Julius D, Gingrich JA, Hamon M, Bourgoin S (2007) Mechanical, thermal and formalin-induced nociception is differentially altered in 5-HT1A / , 5-HT1B / , 5-HT2A / , 5-HT3A / and 5-HTT / knock-out male mice. Pain 130:235–248. Kheramin S, Body S, Ho MY, Velazquez-Martinez DN, Bradshaw CM, Szabadi E, Deakin JF, Anderson IM (2004) Effects of orbital pre- frontal cortex dopamine depletion on inter-temporal choice: a quantitative analysis. Psychopharmacology (Berl) 175:206 –214. Knoch D, Gianotti LR, Pascual-Leone A, Treyer V, Regard M, Hohm- ann M, Brugger P (2006) Disruption of right prefrontal cortex by low-frequency repetitive transcranial magnetic stimulation induces risk-taking behavior. J Neurosci 26:6469 – 6472. Knutson B, Adams CM, Fong GW, Hommer D (2001) Anticipation of increasing monetary reward selectively recruits nucleus accum- bens. J Neurosci 21:RC159. Kundermann B, Krieg JC, Schreiber W, Lautenbacher S (2004) The effect of sleep deprivation on pain. Pain Res Manag 9:25–32. Kupers R, Frokjaer VG, Naert A, Christensen R, Budtz-Joergensen E, Kehlet H, Knudsen GM (2009) A PET [ 18 F]altanserin study of 5-HT2A receptor binding in the human brain and responses to painful heat stimulation. Neuroimage 44:1001–1007. Leknes S, Tracey I (2008) A common neurobiology for pain and pleasure. Nat Rev Neurosci 9:314 –320. Manning BH, Martin WJ, Meng ID (2003) The rodent amygdala con- tributes to the production of cannabinoid-induced antinociception. Neuroscience 120:1157–1170. Manning BH, Mayer DJ (1995) The central nucleus of the amygdala contributes to the production of morphine antinociception in the formalin test. Pain 63:141–152. Mansikka H, Erbs E, Borrelli E, Pertovaara A (2005) Influence of the dopamine D2 receptor knockout on pain-related behavior in the mouse. Brain Res 1052:82– 87. Millan MJ (2002) Descending control of pain. Prog Neurobiol 66:355– 474.

M. Pais-Vieira et al. / Neuroscience 161 (2009) 671– 679

679

Miller EK, Cohen JD (2001) An integrative theory of prefrontal cortex function. Annu Rev Neurosci 24:167–202. Miu AC, Heilman RM, Houser D (2008) Anxiety impairs decision- making: psychophysiological evidence from an Iowa Gambling Task. Biol Psychol 77:353–358. Mizoguchi K, Yuzurihara M, Ishige A, Sasaki H, Chui DH, Tabira T (2000) Chronic stress induces impairment of spatial working mem- ory because of prefrontal dopaminergic dysfunction. J Neurosci 20:1568 –1574. Mobini S, Body S, Ho MY, Bradshaw CM, Szabadi E, Deakin JFW, Anderson IM (2002) Effects of lesions of the orbitofrontal cortex on sensitivity to delayed and probabilistic reinforcement. Psychophar-

macology 160:290 –298.

Mongini F, Keller R, Deregibus A, Barbalonga E, Mongini T (2005) Frontal lobe dysfunction in patients with chronic migraine: a clini- cal-neuropsychological study. Psychiatry Res 133:101–106. Neugebauer V, Fu Y, Ji G, Galhardo V (2007) CRF1 receptors in the basolateral amygdala contribute to pain-related decision-making deficits. Program No. 717 4 Neuroscience Meeting Planner. Wash- ington: Society for Neuroscience. Neugebauer V, Li W, Bird GC, Bhave G, Gereau RW (2003) Synaptic plasticity in the amygdala in a model of arthritic pain: differential roles of metabotropic glutamate receptors 1 and 5. J Neurosci 23:52– 63. Pais-Vieira M, Lima D, Galhardo V (2007) Orbitofrontal cortex lesions disrupt risk assessment in a novel serial decision-making task for rats. Neuroscience 145:225–231. Pellow S, Chopin P, File SE, Briley M (1985) Validation of open: closed arm entries in an elevated plus-maze as a measure of anxiety in the rat. J Neurosci Methods 14:149 –167. Petrovic P, Petersson KM, Ghatan PH, Stone-Elander S, Ingvar M (2000) Pain-related cerebral activation is altered by a distracting cognitive task. Pain 85:19 –30. Ploghaus A, Becerra L, Borras C, Borsook D (2003) Neural circuitry underlying pain modulation: expectation, hypnosis, placebo. Trends Cogn Sci 7:197–200. Porro CA, Baraldi P, Pagnoni G, Serafini M, Facchin P, Maieron M, Nichelli P (2002) Does anticipation of pain affect cortical nocicep- tive systems? J Neurosci 22:3206 –3214. Raichle KA, Hanley M, Jensen MP, Cardenas DD (2007) Cognitions, coping, and social environment predict adjustment to pain in spinal cord injury. J Pain 8:718 –729. Rolls ET, O’Doherty J, Kringelbach ML, Francis S, Bowtell R, McGlone F (2003) Representations of pleasant and painful touch in the human orbitofrontal and cingulate cortices. Cereb Cortex 13:308–317. Roussos P, Giakoumaki SG, Pavlakis S, Bitsios P (2008) Planning, decision-making and the COMT Rs 4818 polymorphism in healthy males. Neuropsychologia 46:757–763. Schmidt-Wilcke T, Luerding R, Weigand T, Jurgens T, Schuierer G, Leinisch E, Bogdahn U (2007) Striatal grey matter increase in patients suffering from fibromyalgia—a voxel-based morphometry study. Pain 132 (Suppl 1):S109 –S116.

Scott DJ, Stohler CS, Egnatuk CM, Wang H, Koeppe RA, Zubieta JK (2007) Individual differences in reward responding explain placebo- induced expectations and effects. Neuron 55:325–336. Sevy S, Hassoun Y, Bechara A, Yechiam E, Napolitano B, Burdick K, Delman H, Malhotra A (2006) Emotion-based decision-making in healthy subjects: short-term effects of reducing dopamine levels. Psychopharmacology (Berl) 188:228 –235. Sindrup SH, Otto M, Finnerup NB, Jensen TS (2005) Antidepressants in the treatment of neuropathic pain. Basic Clin Pharmacol Toxicol 96:399 – 409. Sokol-Hessner P, Hsu M, Curley NG, Delgado MR, Camerer CF, Phelps EA (2009) Thinking like a trader selectively reduces indi- viduals’ loss aversion. Proc Natl Acad Sc iUSA 106:5035–5040. Sultan A, Gaskell H, Derry S, Moore RA (2008) Duloxetine for painful diabetic neuropathy and fibromyalgia pain: systematic review of randomised trials. BMC Neurol 8:29. Tanimoto S, Nakagawa T, Yamauchi Y, Minami M, Satoh M (2003) Differential contributions of the basolateral and central nuclei of the amygdala in the negative affective component of chemical somatic and visceral pains in rats. Eur J Neurosci 18:2343–2350. Tversky A, Kahneman D (1981) The framing of decisions and the psychology of choice. Science 211:453– 458. Valet M, Sprenger T, Boecker H, Willoch F, Rummeny E, Conrad B, Erhard P, Tolle TR (2004) Distraction modulates connectivity of the cingulo-frontal cortex and the midbrain during pain—an fMRI anal- ysis. Pain 109:399 – 408. Vatine JJ, Devor M, Belfer I, Raber P, Zeltser R, Dolina S, Selzer Z (2000) Preoperative open field behavior predicts levels of neuro- pathic pain-related behavior in mice. Neurosci Lett 279:141–144. Wallis JD (2007) Orbitofrontal cortex and its contribution to decision- making. Annu Rev Neurosci 30:31–56. Wernicke JF, Pritchett YL, D’Souza DN, Waninger A, Tran P, Iyengar S, Raskin J (2006) A randomized controlled trial of duloxetine in diabetic peripheral neuropathic pain. Neurology 67:1411–1420. Wood PB, Schweinhardt P, Jaeger E, Dagher A, Hakyemez H, Rabiner EA, Bushnell MC, Chizh BA (2007) Fibromyalgia patients show an abnormal dopamine response to pain. Eur J Neurosci 25:3576 –3582. Woolf CJ (1983) Evidence for a central component of post-injury pain hypersensitivity. Nature 306:686 – 688. Yamamoto S, Ouchi Y, Onoe H, Yoshikawa E, Tsukada H, Takahashi H, Iwase M, Yamaguti K, Kuratsune H, Watanabe Y (2004) Re- duction of serotonin transporters of patients with chronic fatigue syndrome. Neuroreport 15:2571–2574. Zhang YQ, Tang JS, Yuan B, Jia H (1997) Inhibitory effects of elec- trically evoked activation of ventrolateral orbital cortex on the tail- flick reflex are mediated by periaqueductal gray in rats. Pain

72:127–135.

Zimmermann M (1983) Ethical guidelines for investigations of experi- mental pain in conscious animals. Pain 16:109 –110.

(Accepted 4 April 2009) (Available online 8 April 2009)