From the clinic to the lab (and back) : a call for laboratory research to optimize cognitive-behaviour treatment of pain

Cognitive behavioural therapy (CBT) is the dominant psychological treatment for chronic pain. CBT covers a mixture of aims and a broad range of techniques, including attentional control, modification of maladaptive beliefs and coping strategies and flexible goal setting and acceptance. Patients are exposed to varying selections of these strategies, and a major challenge for clinical practice is to determine what works for whom in which context. We propose that incorporating laboratory research into translational behaviour medicine is a critical developmental step that will help optimizing CBT and provide examples of representative experimental research programs

Do flexible goal adjustment and acceptance help preserve quality of life in patients with Multiple Sclerosis?

Background Goal regulation strategies such as flexible goal adjustment and acceptance are believed to be protective factors in persons with chronic illness, but research on their relative contributions to quality of life in multiple sclerosis (MS) is lacking. Purpose We aimed to test the idea that acceptance and flexible goal adjustment (in contrast to tenacious goal pursuit) may help preserve the quality of life in persons with MS. Method A sample of 117 patients with MS was recruited. They completed questionnaires measuring quality of life (physical functioning, psychological distress), acceptance, flexible goal adjustment, and tenacious goal pursuit. Results Acceptance significantly accounted for variance in all three indexes of quality of life, beyond the effects of demographic and illness characteristics. The role of goal regulation style was less clear. Flexible goal adjustment significantly accounted for psychological well-being only. Surprisingly, tenacious goal pursuit predicted better psychological functioning and less psychological distress. No support was found for the hypothesis that acceptance and flexible goal adjustment would moderate the relation between illness severity and quality of life. Conclusion The findings suggest the potential importance of acceptance in understanding MS patients' quality of life, although its hypothesized protective function could not be confirmed. Further conceptual work on acceptance and goal regulation style is needed, as well as prospective work investigating their causal status

Attentional bias towards pain-related information diminishes the efficacy of distraction

Distraction is a strategy that is commonly used to cope with pain. Results concerning the efficacy of distraction from both experimental and clinical studies are variable, however, and indicate that its efficacy may depend on particular circumstances. Several models propose that distraction may be less effective for people who display a large attentional bias towards pain-related information. This hypothesis was tested in an experimental context with 53 pain-free volunteers. First, attentional bias towards cues signalling the occurrence of pain (electrocutaneous stimuli) and towards words describing the sensory experience of this painful stimulus was independently assessed by means of 2 behavioural paradigms (respectively, spatial cueing task and dot-probe task). This was followed by a subsequent distraction task during which the efficacy of distraction, by directing attention away from the electrocutaneous stimuli, was tested. In addition, state-trait anxiety, catastrophic thinking, and initial pain intensity were measured. Results indicated that people who display a large attentional bias towards predictive cues of pain or who initially experience the pain as more painful benefit less from distraction on a subsequent test. No effects were found between attentional bias towards pain words, state-trait anxiety, catastrophic thinking, and the efficacy of distraction. Current findings suggest that distraction should not be used as a 'one size fits all' method to control pain, but only under more specific conditions

A self-regulation perspective on avoidance and persistence behaviour in chronic pain: new theories, new challenges?

Objective: Behavioral factors such as avoidance and persistence have received massive theoretical and empirical attention in the attempts to explain chronic pain and disability. The determinants of these pain behaviors remain, however, poorly understood. We propose a self-regulation perspective to increase our understanding of pain-related avoidance and persistence. Methods: A narrative review. Results: We identified several theoretical views that may help explaining avoidance and persistence behavior, and organized these views around 4 concepts central in self-regulation theories: (1) identity, (2) affective-motivational orientation, (3) goal cognitions, and (4) coping. The review shows that each of these self-regulation perspectives allows for a broadened view in which pain behaviors are not simply considered passive consequences of fear, but proactive strategies to regulate the self when challenged by pain. Discussion: Several implications and challenges arising from this review are discussed. In particular, a self-regulation perspective does not consider avoidance and persistence behavior to be intrinsically adaptive or maladaptive, but argues that their effects on disability and well-being rather depend on the goals underlying these behaviors. Such view would require a shift in how avoidance and persistence behavior are assessed and approached in clinical interventions

Goal pursuit in individuals with chronic pain: a personal project analysis

Objectives: In individuals with chronic pain (ICPs), controlling pain often is a salient goal, despite the difficulty to achieve it. This situation may bring along frustration and distress. Yet much remains unknown about the content, appraisal, and structure of goals that ICPs pursue. Here, we explore these goals, and specifically focus upon possible differences and interrelations between pain control goals (e.g., "to control my pain") and non-pain goals (e.g., "to go to work"). Design and Methods: "Personal Project Analysis" was used in 73 ICPs (48 females; 25 males; M-age = 49.85 years; SD = 9.72) to elicit goals and goal appraisals. Interrelations between pain and non-pain goals, namely interference (i.e., negative influence), facilitation (i.e., positive influence), and necessary condition (i.e., conditional relation between pain control goal and non-pain goals) were measured with three items. Self-report measures of pain intensity, pain catastrophizing, problem solving and acceptance were completed. Results: Participants reported a variety of goals. Appraisals of pain control goals were less favorable than appraisals of non-pain goals. ICPs with higher acceptance and meaningfulness of life reported more control over pain goals, and more progress in reaching pain control goals. These individuals also reported an overall much more positive appraisal of non-pain goals (i.e., less stress, difficulty, more progress, control). In contrast, high catastrophizing and the need to solve pain were negatively related to goal appraisals. Importantly. ICP's with high perceived meaningfulness of life despite pain experienced less necessity to achieve pain control goals in order to achieve non-pain goals. This was opposite for individuals with high levels of catastrophizing. Discussion: An understanding of why ICPs may become stuck in attempts to control their pain does not only require an understanding of how individuals appraise their pain, but also requires an understanding of how pain and non-pain goals interrelate. In particular, the view that controlling pain is necessary in order to be able to achieve other goals seems detrimental

No evidence for threat-induced spatial prioritization of somatosensory stimulation during pain control using a synchrony judgment paradigm

Topical research efforts on attention to pain often take a critical look at the modulatory role of top-down factors. For instance, it has been shown that the fearful expectation of pain at a location of the body directs attention towards that body part. In addition, motivated attempts to control this pain were found to modulate this prioritization effect. Such studies have often used a temporal order judgment task, requiring participants to judge the order in which two stimuli are presented by indicating which one they perceived first. As this constitutes a forced-choice response format, such studies may be subject to response bias. The aim of the current study was to address this concern. We used a ternary synchrony judgment paradigm, in which participants judged the order in which two somatosensory stimuli occurred. Critically, participants now also had the option to give a `simultaneous' response when they did not perceive a difference. This way we eliminated the need for guessing, and thus reduced the risk of response bias. One location was threatened with the possibility of pain in half of the trials, as predicted by an auditory cue. Additionally, half of the participants (pain control group) were encouraged to avoid pain stimuli by executing a quick button press. The other half (comparison group) performed a similar action, albeit unrelated to the occurrence of pain. Our data did not support threat-induced spatial prioritization, nor did we find evidence that pain control attempts influenced attention in any way