Altered Decision-Making Across Acute and Chronic Pain States: A Bias Towards Context-Dependent Valuations

Chronic pain is often characterized by the entrenchment of maladaptive behaviors -- avoidance, inactivity, and hypervigilance -- that outlast tissue damage. A central but mechanistically underspecified question is how behaviors acquired during acute pain become locked in as pain chronifies. Influential accounts, including the fear-avoidance model, suggest that behavioral patterns learned in a specific context -- such as avoidance during acute injury -- overgeneralize to situations where they are no longer advantageous. Whether this reflects altered learning or changes in how learned information guides decisions has remained unclear. To address this, we administered a probabilistic reinforcement learning task to 239 individuals with chronic pain, acute pain, or no pain, designed to dissociate two decision strategies: reliance on recent reinforcement history -- what was reinforced in a prior context -- versus global expected value -- the objective worth of an option regardless of context. Learning performance was comparable across all groups, confirming intact associative learning. However, groups differed significantly in decision-making: individuals with chronic pain favored options with stronger context-dependent reinforcement history over those with higher global expected value; however, those without pain showed no preference for one over the other, with the acute pain group showing an intermediate pattern. Computational modeling confirmed this, with chronic pain patients showing significantly reduced weighting toward global expected value. Critically, this shift tracked pain duration rather than intensity -- suggesting prolonged pain exposure gradually biases decisions away from global expected value towards a context-dependent history. These findings offer a computational explanation for behavioral persistence in chronic pain, and this duration-dependent shift, already evident in the acute pain group, may represent an early cognitive signature of chronification.