Pain and suffering attacking when not unconscious
 

https://imgur.com/a/lRV80Ww

Pain and suffering took a swing at me at 25% hp.

This may, coincidentally, be the amount of HP I have from items and buffs.

Wild-ass guess: Wondering if there is a boundary bug, where pain and suffering will swing if you get a tick and you're at 0 to -10 your natural HP before items and buffs.

In any case, pain and suffering shouldn't be swinging unless I'm unconscious I would think.

If I'm not mistaken, pain and suffering can hit you at any percentage of your hp. Is basically when you kill a mob and it hits you after it died (client/server sync thingamajig). Looks like that is what happened in your screenshot