More than Meets the Eye: Visual Attention Biases in Individuals with Chronic Pain

The present study used eye-tracking technology to assess whether individuals who report chronic pain direct more attention to sensory pain-related words than do pain-free individuals. A total of 113 participants (51 with chronic pain, 62 pain-free) were recruited. Participants completed a dot-probe task, viewing neutral and sensory pain-related words while their reaction time and eye movements were recorded. Data were analyzed by mixed-design ANOVA with Group (chronic pain vs. pain-free) and Word type (sensory pain vs. neutral). Results showed a significant Group x Word type interaction effect for number of fixations, average visit duration, and late phase fixation duration, all greater for sensory pain vs. neutral words in the chronic pain group. None of the effects for reaction time was significant. Findings support the hypothesis that individuals with chronic pain display attentional biases towards pain-related stimuli and demonstrate the value of eye-tracking technology in measuring differences in visual attention variables

More than meets the eye: visual attention biases in individuals reporting chronic pain

The present study used eye-tracking technology to assess whether individuals who report chronic pain direct more attention to sensory pain-related words than do pain-free individuals. A total of 113 participants (51 with chronic pain, 62 pain-free) were recruited. Participants completed a dot-probe task, viewing neutral and sensory pain-related words while their reaction time and eye movements were recorded. Eye-tracking data were analyzed by mixed-design analysis of variance with group (chronic pain versus pain-free) as the between-subjects factor, and word type (sensory pain versus neutral) as the within-subjects factor. Results showed a significant main effect for word type: all participants attended to pain-related words more than neutral words on several eye-tracking parameters. The group main effect was significant for number of fixations, which was greater in the chronic pain group. Finally, the group by word type interaction effect was significant for average visit duration, number of fixations, and total late-phase duration, all greater for sensory pain versus neutral words in the chronic pain group. As well, participants with chronic pain fixated significantly more frequently on pain words than did pain-free participants. In contrast, none of the effects for reaction time were significant. The results support the hypothesis that individuals with chronic pain display specific attentional biases toward pain-related stimuli and demonstrate the value of eye-tracking technology in measuring differences in visual attention variables.Samantha Fashler is supported by an Ontario Graduate Scholarship and a Canadian Institutes of Health Research (CIHR) Frederick Banting and Charles Best CGS Master’s Award. Joel Katz is supported by a CIHR Canada Research Chair (CRC) in Health Psychology. Funds to support the project were obtained from Dr Katz’s CRC. We are grateful to Dr. Paul Ritvo for providing partial funding for the purchase of the Tobii eye-tracker through a Federal Development Grant. This article was derived, in part, from Samantha Fashler’s master’s thesis

Keeping an eye on pain: investigating visual attention biases in individuals with chronic pain using eye-tracking methodology

Attentional biases to painful stimuli are evident in individuals with chronic pain, although the directional tendency of these biases (ie, toward or away from threat-related stimuli) remains unclear. This study used eye-tracking technology, a measure of visual attention, to evaluate the attentional patterns of individuals with and without chronic pain during exposure to injury-related and neutral pictures. Individuals with (N=51) and without chronic pain (N=62) completed a dot-probe task using injury-related and neutral pictures while their eye movements were recorded. Mixed-design analysis of variance evaluated the interaction between group (chronic pain, pain-free) and picture type (injury-related, neutral). Reaction time results showed that regardless of chronic pain status, participants responded faster to trials with neutral stimuli in comparison to trials that included injury-related pictures. Eye-tracking measures showed within-group differences whereby injury-related pictures received more frequent fixations and visits, as well as longer average visit durations. Between-group differences showed that individuals with chronic pain had fewer fixations and shorter average visit durations for all stimuli. An examination of how biases change over the time-course of stimulus presentation showed that during the late phase of attention, individuals with chronic pain had longer average gaze durations on injury pictures relative to pain-free individuals. The results show the advantage of incorporating eye-tracking methodology when examining attentional biases, and suggest future avenues of research.We are grateful to Dr Paul Ritvo for his assistance. Samantha Fashler was supported by an Ontario Graduate Scholarship, a Canadian Institutes of Health Research (CIHR) CGS Master’s Award, and a CIHR Vanier Canada Graduate Scholarship. Joel Katz is supported by a CIHR Canada Research Chair (CRC) in Health Psychology. Funds to support the project were obtained from Dr Katz’s CRC and Dr Ritvo’s Federal Development Program. This article was derived, in part, from Samantha Fashler’s Master’s thesis. The research in this manuscript was presented as a poster presentation at the Canadian Pain Society in May 2014. An abstract of the poster was published in Pain Research & Management (vol 19, issue 3, e31–e102, 2014)

Chronic pain, psychopathology, and DSM-5 somatic symptom disorder

Unlike acute pain that warns us of injury or disease, chronic or persistent pain serves no adaptive purpose. Though there is no agreed on definition of chronic pain, it is commonly referred to as pain that is without biological value, lasting longer than the typical healing time, not responsive to treatments based on specific remedies, and of a duration greater than 6 months. Chronic pain that is severe and intractable has detrimental consequences, including psychological distress, job loss, social isolation, and, not surprisingly, it is highly comorbid with depression and anxiety. Historically, pain without an apparent anatomical or neurophysiological origin was labelled as psychopathological. This approach is damaging to the patient and provider alike. It pollutes the therapeutic relationship by introducing an element of mutual distrust as well as implicit, if not explicit, blame. It is demoralizing to the patient who feels at fault, disbelieved, and alone. Moreover, many medically unexplained pains are now understood to involve an interplay between peripheral and central neurophysiological mechanisms that have gone awry. The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, somatic symptom disorder overpsychologizes people with chronic pain; it has low sensitivity and specificity, and it contributes to misdiagnosis, as well as unnecessary stigma. Adjustment disorder remains the most appropriate, accurate, and acceptable diagnosis for people who are overly concerned about their pain.Preparation of this manuscript was facilitated by support from a Canadian Institutes of Health Research (CIHR) Canada Research Chair in Health Psychology awarded to Dr Katz and a CIHR Canada Graduate Master’s Award to Samantha Fashler

Systematic Review of Multidisciplinary Chronic Pain Treatment Facilities

This study reviewed the published literature evaluating multidisciplinary chronic pain treatment facilities to provide an overview of their availability, caseload, wait times, and facility characteristics. A systematic literature review was conducted using PRISMA guidelines following a search of MEDLINE, PsycINFO, and CINAHL databases. Inclusion criteria stipulated that studies be original research, survey more than one pain treatment facility directly, and describe a range of available treatments. Fourteen articles satisfied inclusion criteria. Results showed little consistency in the research design used to describe pain treatment facilities. Availability of pain treatment facilities was scarce and the reported caseloads and wait times were generally high. A wide range of medical, physical, and psychological pain treatments were available. Most studies reported findings on the percentage of practitioners in different health care professions employed. Future studies should consider using more comprehensive search strategies to survey facilities, improving clarity on what is considered to be a pain treatment facility, and reporting on a consistent set of variables to provide a clear summary of the status of pain treatment facilities. This review highlights important information for policymakers on the scope, demand, and accessibility of pain treatment facilities.Samantha Fashler is supported by an Ontario Graduate Scholarship and a Canadian Institutes of Health Research (CIHR) Vanier Canada Graduate Scholarship. Lindsay Burns is supported by a Frederick Banting and Charles Best CIHR Doctoral Scholarship. Joel Katz is supported by a CIHR Canada Research Chair in Health Psychology. This project was conducted in collaboration with the Canadian Pain Coalition (CPC) as a part of the Report Card on Pain

Results from 10 Years of a CBT Pain Self-Management Outpatient Program for Complex Chronic Conditions

Background. Traditional unimodal interventions may be insufficient for treating complex pain, as they do not address cognitive and behavioural contributors to pain. Cognitive Behavioural Therapy (CBT) and physical exercise (PE) are empirically supported treatments that can reduce pain and improve quality of life. Objectives. To examine the outcomes of a pain self-management outpatient program based on CBT and PE at a rehabilitation hospital in Toronto, Ontario. Methods. The pain management group (PMG) consisted of 20 sessions over 10 weeks. The intervention consisted of four components: education, cognitive behavioural skills, exercise, and self-management strategies. Outcome measures included the sensory, affective, and intensity of pain experience, depression, anxiety, pain disability, active and passive coping style, and general health functioning. Results. From 2002 to 2011, 36 PMGs were run. In total, 311 patients entered the program and 214 completed it. Paired t-tests showed significant pre- to posttreatment improvements in all outcomes measured. Patient outcomes did not differ according to the number or type of diagnoses. Both before and after treatment, women reported more active coping than men. Discussion. The PMGs improved pain self-management for patients with complex pain. Future research should use a randomized controlled design to better understand the outcomes of PMGs

Heart rate variability is enhanced in controls but not maladaptive perfectionists during brief mindfulness meditation following stress-induction: A stratified-randomized trial

Heart rate variability (HRV) is a vagal nerve-mediated biomarker of cardiac function used to investigate chronic illness, psychopathology, stress and, more recently, attention-regulation processes such as meditation. This study investigated HRV in relation to maladaptive perfectionism, a stress-related personality factor, and mindfulness meditation, a stress coping practice expected to elevate HRV, and thereby promote relaxation. Maladaptive perfectionists (n=21) and Controls (n=39) were exposed to a lab-based assessment in which HRV was measured during (1) a 5-minute baseline resting phase, (2) a 5-minute cognitive stress-induction phase, and (3) a post-stress phase. In the post-stress phase, participants were randomly assigned to a 10-minute audio instructed mindfulness meditation condition or a 10-minute rest condition with audio-description of mindfulness meditation. Analyses revealed a significant elevation in HRV during meditation for Controls but not for Perfectionists. These results suggest that mindfulness meditation promotes relaxation following cognitive stress and that the perfectionist personality hinders relaxation possibly because of decreased cardiac vagal tone. The results are discussed in the context of developing psychophysiological models to advance therapeutic interventions for distressed populations.The authors have no conflicts of interest: they have no financial or personal relationships with other people or organizations that could inappropriately influence their work. The authors gratefully acknowledge the assistance of all persons and volunteers whose participation was essential in the successful completion of the study. The authors would also like to thank Professor John B. Allen for his advice on HRV analysis, and the Statistical Consulting Service offered by the Institute for Social Research at York University. Joel Katz is supported by a Canadian Institutes of Health Research Canada Research Chair in Health Psychology

The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain

Chronic postsurgical pain (CPSP), an often unanticipated result of necessary and even life-saving procedures, develops in 5–10% of patients one-year after major surgery. Substantial advances have been made in identifying patients at elevated risk of developing CPSP based on perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. The Transitional Pain Service (TPS) at Toronto General Hospital (TGH) is the first to comprehensively address the problem of CPSP at three stages: 1) preoperatively, 2) postoperatively in hospital, and 3) postoperatively in an outpatient setting for up to 6 months after surgery. Patients at high risk for CPSP are identified early and offered coordinated and comprehensive care by the multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physiotherapists. Access to expert intervention through the Transitional Pain Service bypasses typically long wait times for surgical patients to be referred and seen in chronic pain clinics. This affords the opportunity to impact patients’ pain trajectories, preventing the transition from acute to chronic pain, and reducing suffering, disability, and health care costs. In this report, we describe the workings of the Transitional Pain Service at Toronto General Hospital, including the clinical algorithm used to identify patients, and clinical services offered to patients as they transition through the stages of surgical recovery. We describe the role of the psychological treatment, which draws on innovations in Acceptance and Commitment Therapy that allow for brief and effective behavioral interventions to be applied transdiagnostically and preventatively. Finally, we describe our vision for future growth.Joel Katz is supported by Canadian Institutes of Health Research Canada Research Chair in Health Psychology at York University. Hance Clarke is supported by a Merit Award from the Department of Anesthesia, University of Toronto and received funding from the Ontario Ministry of Health and Long Term Care, Medically Complex Patients Demonstration Project Program for a project entitled “The Transitional Pain Service Demonstration Project”

Validation of the Sensitivity to Pain Traumatization Scale

The present dissertation examines the psychometric properties of the Sensitivity to Pain Traumatization Scale (SPTS-12), a measure developed to assess the cognitive, emotional, behavioural, and somatic responses to pain that are similar to a traumatic stress response. The literature review provides a description of the definition, models, and burden of chronic pain and trauma, as well as a discussion of the high rates of comorbidity between chronic pain and trauma. Next, common pain-related anxiety measures are described followed by a summary of the development of the SPTS-12. Three studies are presented that examine the psychometric properties of the SPTS-12. Study 1 evaluates the factor structure, reliability, and validity of the SPTS-12 in a sample of 823 undergraduate students who were pain-free or reported experiencing ongoing pain. For both groups, the one-factor model demonstrated adequate overall fit and the SPTS-12 total score showed excellent reliability and good convergent validity with a measure of trauma symptoms, with mixed findings regarding the divergent validity of the SPTS-12 when examined against a measure of depressive symptoms. Study 2 explores the factor structure, reliability, and validity of the SPTS-12 in a clinical sample of 180 patients receiving care in an outpatient multidisciplinary service designed to help prevent the development of chronic postsurgical pain. Confirmatory factor analysis supported the one-factor model of the SPTS-12, with evidence of excellent internal consistency reliability. The SPTS-12 demonstrated good convergent validity, but divergent validity was not supported. Study 3 uses latent class mixed models to represent trajectories of SPTS-12 scores in a clinical sample of 361 patients after surgery. The optimally-fitting model consisted of five SPTS-12 trajectories, three of which were characterized by significantly decreasing scores over time. Analysis of pain-related outcomes predicted by SPTS-12 trajectories provide evidence of criterion validity of the SPTS-12. Across all three studies, the results indicate that the SPTS-12 provides a way to more directly measure traumatization that individuals may experience in response to pain, which may contribute to our understanding of why trauma and pain co-occur so frequently. Given the high incidence of pain and trauma, as well as the established efficacy of psychotherapy in treating pain after surgery, the present results suggest that tailoring treatment to better address trauma-specific symptoms may help improve pain management treatment strategies. Limitations include several large residual correlations between some items of the SPTS-12 in Study 1. Furthermore, in all three studies, the samples were highly heterogeneous and may not have identified differences among distinct subsamples. Additionally, missing data may have contributed to a systematic bias that only captures participants who provided adequate responses. Possible future directions include developing alternate wording for the item with the poorest fit on the SPTS-12, evaluating the concurrent validity of the SPTS-12 by examining its relationship with clinically relevant mental health diagnoses, and validating the SPTS-12 in different patient and community populations. In summary, the present dissertation provides evidence of strong psychometric properties of the SPTS-12 and encourages ongoing refinement and validation of the scale