Understanding persistent physical symptoms: Conceptual integration of psychological expectation models and predictive processing accounts

Patient Expectations and Therapeutic Alliance Affect Pain Reduction Following Lidocaine Infusion in an Interdisciplinary Chronic Pain Clinic

Pain experience is affected by both ascending nociceptive signals and descending modulation. Expectations can affect pain experience and augment treatment-induced analgesia through descending inhibitory modulation of pain. This open-label, prospective cohort study examined the association between participant expectation ratings and pain reduction in adult participants with chronic pain receiving an intravenous lidocaine infusion. We aimed to explore whether: 1) participants' expectations of treatment efficacy were associated with pain reduction over 8 weeks after infusion; and 2) participants' therapeutic alliance was associated with expectations and/or pain reduction. We recruited 70 participants with chronic pain scheduled for lidocaine infusion. Study measures included pain intensity (pre-treatment, post-treatment, and daily for 8 weeks), treatment expectations (EXPECT), and therapeutic alliance (Trust in Physician and Working Alliance Inventory-Short Revised). Baseline treatment expectations were significantly correlated with pain reduction (r = .42, P < .01). Therapeutic alliance was significantly correlated with expectations (r = .27, P < .05) and pain reduction (r = .38, P < .01). This study quantifies the contribution of: 1) treatment expectations; and 2) therapeutic alliance to the magnitude of lidocaine-induced pain reduction. Results generate the hypothesis that focused efforts to augment treatment expectations and therapeutic alliance could serve to improve pain treatment outcomes. PERSPECTIVE: This study evaluates the relationship between pain reduction and ratings of: 1) treatment expectations; and 2) therapeutic alliance following an intravenous lidocaine infusion. Results generate the hypothesis that focused efforts to augment treatment expectations and therapeutic alliance could serve to improve pain treatment outcomes.

Expanding the notion of mechanism to further understanding of biopsychosocial disorders? Depression and medically-unexplained pain as cases in point

Evidence-Based Medicine has little consideration for mechanisms and philosophers of science and medicine have recently made pleas to increase the place of mechanisms in the medical evidence hierarchy. However, in this debate the notions of mechanisms seem to be limited to 'mechanistic processes' and 'complex-systems mechanisms,' understood as 'componential causal systems'. I believe that this will not do full justice to how mechanisms are used in biological, psychological and social sciences and, consequently, in a more biopsychosocial approach to medicine. Here, I propose, following (Kuorikoski, 2009), to pay more attention to 'abstract forms of interaction' mechanisms. The present work scrutinized review articles on depression and medically unexplained pain, which are considered to be of multifactorial pathogenesis, for their use of mechanisms. In review articles on these disorders there seemed to be a range of uses between more 'abstract forms of interaction' and 'componential causal system' mechanisms. I therefore propose to expand the notions of mechanisms considered in medicine to include that of more 'abstract forms of interaction' to better explain and manage biopsychosocial disorders.

Soreness Reminds Me of Grief: Patients With Chronic Pain Show Less Differentiated Representations of Emotional Feelings and Bodily States

People experience similarities between emotional feelings and bodily states on a daily basis, but both the magnitude and pervasiveness of this experiential similarity vary across individuals. Inspired by previous findings that chronic pain (CP) is characterized by strengthened pain-affect coupling and reduced interoceptive accuracy, we conducted 2 cross-sectional studies to examine whether patients with CP would exhibit less differentiated perception and mental representation of emotional feelings and bodily states. In study 1 (N = 500), patients with CP and healthy controls (HCs) completed a self-report questionnaire that asked explicitly about the perceived similarity between 5 basic emotion categories and a series of bodily states. In study 2 (N = 73), a specially designed false memory test was administered to examine whether patients with CP would have reduced differentiation of concepts of negative emotion and somatic distress. We found that patients with CP perceived greater and more pervasive similarities between emotional feelings and bodily states, as indicated by higher questionnaire scores and denser, less specialized bipartite emotion-body networks, both associated with lower subjective interoceptive accuracy. Furthermore, patients with CP formed false memories of negative emotion words (eg, grief) more readily than HCs after memorizing somatic distress words (eg, soreness), as if they represented negative emotion and somatic distress as a single, enmeshed semantic category. Our findings extend previous literature by demonstrating reduced discrimination between emotional and bodily experiences in CP that is not restricted to pain-related emotional and sensory experiences and may be related to a fundamentally less differentiated interoception. PERSPECTIVES: This study shows that patients with chronic pain have a profoundly less differentiated perception and implicit conceptualization of emotional feelings and bodily states, which appears to be associated with altered interoception. These findings may provide new perspectives on why they often experience a stronger pain-affect coupling.

Does Active Inference Provide a Comprehensive Theory of Placebo Analgesia?

Placebo interventions generate mismatches between expected pain and sensory signals from which pain states are inferred. Because we lack direct access to bodily states, we can only infer whether nociceptive activity indicates tissue damage or results from noise in sensory channels. Predictive processing models propose to make optimal inferences using prior knowledge given noisy sensory data. However, these models do not provide a satisfactory explanation of how pain relief expectations are translated into physiological manifestations of placebo responses. Furthermore, they do not account for individual differences in the ability to endogenously regulate nociceptive activity in predicting placebo analgesia. The brain not only passively integrates prior pain expectations with nociceptive activity to infer pain states (perceptual inference) but also initiates various types of actions to ensure that sensory data are consistent with prior pain expectations (active inference). We argue that depending on whether the brain interprets conflicting sensory data (prediction errors) as a signal to learn from or noise to be attenuated, the brain initiates opposing types of action to facilitate learning from sensory data or, conversely, to enhance the biasing influence of prior pain expectations on pain perception. Furthermore, we discuss the role of stress, anxiety, and unpredictability of pain in influencing the weighting of prior pain expectations and sensory data and how they relate to the individual ability to regulate nociceptive activity (endogenous pain modulation). Finally, we provide suggestions for future studies to test the implications of the active inference model of placebo analgesia.

Acquiring a new understanding of illness and agency: a narrative study of recovering from chronic fatigue syndrome

BACKGROUND

The condition known as chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) is poorly understood. Simplified medical models tend to neglect the complexity of illness, contributing to a terrain of uncertainty, dilemmas and predicaments. However, despite pessimistic pictures of no cure and poor prognosis, some patients recover.

PURPOSE

This study's purpose is to provide insight into people's experiences of suffering and recovery from very severe CFS/ME and illuminate understanding of how and why changes became possible.

METHODS

Fourteen former patients were interviewed about their experiences of returning to health. A narrative analysis was undertaken to explore participants' experiences and understandings. We present the result through one participant's story.

RESULTS

The analysis yielded a common plotline with a distinct turning point. Participants went through a profound narrative shift, change in mindset and subsequent long-time work to actively pursue their own healing. Their narrative understandings of being helpless victims of disease were replaced by a more complex view of causality and illness and a new sense of self-agency developed.

DISCUSSION

We discuss the illness narratives in relation to the disease model and its shortcomings, the different voices dominating the stories at different times in a clinically, conceptually, and emotionally challenging area.

Chronic fatigue syndromes: real illnesses that people can recover from

The 'Oslo Chronic Fatigue Consortium' consists of researchers and clinicians who question the current narrative that chronic fatigue syndromes, including post-covid conditions, are incurable diseases. Instead, we propose an alternative view, based on research, which offers more hope to patients. Whilst we regard the symptoms of these conditions as real, we propose that they are more likely to reflect the brain's response to a range of biological, psychological, and social factors, rather than a specific disease process. Possible causes include persistent activation of the neurobiological stress response, accompanied by associated changes in immunological, hormonal, cognitive and behavioural domains. We further propose that the symptoms are more likely to persist if they are perceived as threatening, and all activities that are perceived to worsen them are avoided. We also question the idea that the best way to cope with the illness is by prolonged rest, social isolation, and sensory deprivation.Instead, we propose that recovery is often possible if patients are helped to adopt a less threatening understanding of their symptoms and are supported in a gradual return to normal activities. Finally, we call for a much more open and constructive dialogue about these conditions. This dialogue should include a wider range of views, including those of patients who have recovered from them.

Long COVID as a functional somatic symptom disorder caused by abnormally precise prior expectations during Bayesian perceptual processing: A new hypothesis and implications for pandemic response

This review proposes a model of Long-COVID where the constellation of symptoms are in fact genuinely experienced persistent physical symptoms that are usually functional in nature and therefore potentially reversible, that is, Long-COVID is a somatic symptom disorder. First, we describe what is currently known about Long-COVID in children and adults. Second, we examine reported "Long-Pandemic" effects that create a risk for similar somatic symptoms to develop in non-COVID-19 patients. Third, we describe what was known about somatization and somatic symptom disorder before the COVID-19 pandemic, and suggest that by analogy, Long-COVID may best be conceptualized as one of these disorders, with similar symptoms and predisposing, precipitating, and perpetuating factors. Fourth, we review the phenomenon of mass sociogenic (functional) illness, and the concept of nocebo effects, and suggest that by analogy, Long-COVID is compatible with these descriptions. Fifth, we describe the current theoretical model of the mechanism underlying functional disorders, the Bayesian predictive coding model for perception. This model accounts for moderators that can make symptom inferences functionally inaccurate and therefore can explain how to understand common predisposing, precipitating, and perpetuating factors. Finally, we discuss the implications of this framework for improved public health messaging during a pandemic, with recommendations for the management of Long-COVID symptoms in healthcare systems. We argue that the current public health approach has induced fear of Long-COVID in the population, including from constant messaging about disabling symptoms of Long-COVID and theorizing irreversible tissue damage as the cause of Long-COVID. This has created a self-fulfilling prophecy by inducing the very predisposing, precipitating, and perpetuating factors for the syndrome. Finally, we introduce the term "Pandemic-Response Syndrome" to describe what previously was labeled Long-COVID. This alternative perspective aims to stimulate research and serve as a lesson learned to avoid a repeat performance in the future.

Risk factors and protective factors of acute postoperative pain: an observational study at a German university hospital with cross-sectional and longitudinal inpatient data

OBJECTIVES

Surgical fear is one of the most important psychological risk factors for postoperative pain, but less is known about the contribution of protective factors. This study investigated somatic and psychological risk and resilience factors of postoperative pain and validated the German version of the Surgical Fear Questionnaire (SFQ).

SETTING

University Hospital of Marburg, Germany.

DESIGN

Single-centre observational study and cross-sectional validation study.

PARTICIPANTS

Data for validating the SFQ were obtained from a cross-sectional observational study (N=198, mean age 43.6 years, 58.8% female) with persons undergoing different kinds of elective surgery. A sample of N=196 (mean age 43.0 years, 45.4% female) undergoing elective (orthopaedic) surgery was analysed to investigate somatic and psychological predictors of relevant acute postsurgical pain (APSP).

OUTCOME MEASURES

Participants completed preoperative and postoperative assessments at postoperative days 1, 2 and 7. Presurgical pain, age, gender, pain expectation, surgical setting, physical status, anaesthesia, surgical fear, pain catastrophising, depression, optimism and self-efficacy were examined as predictors.

RESULTS

Confirmatory factor analysis confirmed the original two-factor structure of the SFQ. Correlation analyses indicated good convergent and divergent validity. Internal consistency (Cronbach's α) was between 0.85 and 0.89. Blockwise logistic regression analyses for the risk of APSP revealed outpatient setting, higher preoperative pain, younger age, more surgical fear and low dispositional optimism as significant predictors.

CONCLUSIONS

The German SFQ is a valid, reliable and economical instrument with which the important psychological predictor surgical fear can be assessed. Modifiable factors that increase the risk of postoperative pain were higher pain intensity before surgery and being fearful about negative consequences of the surgery whereas positive expectations seem to buffer against postsurgical pain.

TRIAL REGISTRATION NUMBERS

DRKS00021764 and DRKS00021766.

Negative language use of the physiotherapist in low back pain education impacts anxiety and illness beliefs: A randomised controlled trial in healthy respondents

OBJECTIVE

This study aimed to determine the effect of physiotherapists' negative language use on nocebo effects of state anxiety and illness beliefs.

METHODS

A web-based randomised controlled trial included adults without recent musculoskeletal pain. The intervention was a short educational video about low back pain using negative language (nocebo condition: n = 87) versus a video using neutral or positive language (control condition: n = 82). State anxiety was assessed using the State-Trait Anxiety Inventory. Illness beliefs were assessed using the Illness Perception Questionnaire.

RESULTS

Nocebo and control groups differed in outcome measures (MANOVA Pillai's trace = 0.22, F = 4.98; df = (9,159), p < 0.001). Post-hoc analyses showed a medium to large effect for the nocebo condition on anxiety (d = 0.71, 95% CI 0.4 -1.0). The nocebo group also had higher scores in three illness beliefs: beliefs on timeline (d = 0.45, 95% CI 0.14 - 0.75), treatment control (d = 0.43, 95% CI 0.12 - 0.74) and concern (d = 0.47, 95% CI 0.16 - 0.78).

CONCLUSION

Physiotherapists' use of negative language contributes directly to a higher state anxiety and illness beliefs that can trigger the nocebo effects in the recipient PRACTICE IMPLICATIONS: Negative language use should be avoided.

Somatic symptom profiles are associated with pre-treatment depression and anxiety symptom severity but not inpatient therapy outcomes

OBJECTIVE.

Although somatic symptoms are common among mental health patients, their association with symptom severity and inpatient treatment outcomes is not yet well understood.

METHODS.

Using a pre-post design and latent class analysis (LCA), 641 inpatients (63.4% female) were classified based on their self-reported somatic symptoms. We examined how the resulting somatic symptom classes related to depression and anxiety symptom severity pre-treatment (T1) and to symptom reduction post-treatment (T2).

RESULTS.

Our results suggest four somatic symptom classes, namely (1) unspecific/low somatic symptom burden, (2) sexual problems, (3) gastrointestinal symptoms with pain syndrome, and (4) cardiopulmonary symptoms. While class 1 indicated the lowest pre-treatment depression and anxiety symptom severity, class 2 reported high depressive symptoms coupled with low anxiety, class 3 reported moderate depressive and anxiety symptom severity, and class 4 reported the highest depressive and anxiety symptom burden. Somatic symptom classes, however, did not predict the degree of reduction in either depression or anxiety symptoms post-treatment.

CONCLUSIONS.

These findings demonstrate somatic heterogeneity in mental health patients and reveal the relationship of somatic symptom patterns to affective symptom severity. Clinical implications are discussed.

Computational psychiatry: from synapses to sentience

This review considers computational psychiatry from a particular viewpoint: namely, a commitment to explaining psychopathology in terms of pathophysiology. It rests on the notion of a generative model as underwriting (i) sentient processing in the brain, and (ii) the scientific process in psychiatry. The story starts with a view of the brain-from cognitive and computational neuroscience-as an organ of inference and prediction. This offers a formal description of neuronal message passing, distributed processing and belief propagation in neuronal networks; and how certain kinds of dysconnection lead to aberrant belief updating and false inference. The dysconnections in question can be read as a pernicious synaptopathy that fits comfortably with formal notions of how we-or our brains-encode uncertainty or its complement, precision. It then considers how the ensuing process theories are tested empirically, with an emphasis on the computational modelling of neuronal circuits and synaptic gain control that mediates attentional set, active inference, learning and planning. The opportunities afforded by this sort of modelling are considered in light of in silico experiments; namely, computational neuropsychology, computational phenotyping and the promises of a computational nosology for psychiatry. The resulting survey of computational approaches is not scholarly or exhaustive. Rather, its aim is to review a theoretical narrative that is emerging across subdisciplines within psychiatry and empirical scales of investigation. These range from epilepsy research to neurodegenerative disorders; from post-traumatic stress disorder to the management of chronic pain, from schizophrenia to functional medical symptoms.

Subjective and objective cognitive function in adolescent with chronic fatigue following Epstein-Barr virus infection

OBJECTIVE

Cognitive difficulties are among the most disruptive and disabling problems reported by chronic fatigue syndrome (CFS) sufferers. Acute Epstein-Barr virus (EBV) infection is a trigger of chronic fatigue (CF) and CFS. The aim of this study was to investigate subjectively reported and objectively measured cognitive functioning in fatigued and non-fatigued adolescents six months after EBV infection.

METHODS

A total of 195 adolescents (12-19 years) with acute EBV infection were followed prospectively for six months, after which they were grouped as chronically fatigued (CF⁺) and non-fatigued (CF^-) cases based on questionnaire score; the CF⁺-group was further subgrouped according to CFS diagnosis. A group of 70 healthy controls was also included. Groups were cross-sectionally compared on objective measures of processing speed, executive functions and memory, and subjective cognitive functioning.

RESULTS

There were no group differences regarding objective cognitive measures, but the CF⁺-group reported significantly (p < 0.001) more cognitive problems (cognitive symptoms sum score = 9.5) compared to the CF^--group (cognitive symptoms sum score = 5.3) and the healthy control group (cognitive symptoms sum score = 6.4). The CFS subgroup rated symptoms scores even higher but did not differ on cognitive performance tests.

CONCLUSION

Subjective experiences of cognitive difficulties characterize adolescents with CF and CFS six months after acute EBV infection, whereas objective measures of cognitive impairment are inconspicuous.

Risk factors for worsening of somatic symptom burden in a prospective cohort during the COVID-19 pandemic

Introduction

Little is known about risk factors for both Long COVID and somatic symptoms that develop in individuals without a history of COVID-19 in response to the pandemic. There is reason to assume an interplay between pathophysiological mechanisms and psychosocial factors in the etiology of symptom persistence.

Objective

Therefore, this study investigates specific risk factors for somatic symptom deterioration in a cohort of German adults with and without prior SARS-CoV-2 infection.

Methods

German healthcare professionals underwent SARS-CoV-2 IgG antibody testing and completed self-rating questionnaires at baseline and 21 months later between April 2020 and February 2022. Differences in variables between the time points were analyzed and a regression analysis was performed to predict somatic symptom deterioration at follow-up.

Results

Seven hundred fifty-one adults completed both assessments. Until follow-up, n = 58 had contracted SARS-CoV-2 confirmed by serology. Between baseline and follow-up, signs of mental and physical strain increased significantly in the sample. Symptom expectations associated with COVID-19 and a self-reported history of COVID-19, but not serologically confirmed SARS-CoV-2 infection, significantly predicted somatic symptom deterioration at follow-up. A further predictor was baseline psychological symptom burden.

Conclusions

This study supports a disease-overarching biopsychosocial model for the development of burdensome somatic symptoms during the COVID-19 pandemic and supports research findings that symptom burden may be more related to the psychosocial effects of the pandemic than to infection itself. Future studies on Long COVID should include SARS-CoV-2 negative control groups and consider symptom burden prior to infection in order to avoid an overestimation of prevalence rates.

Negative expectations regarding interpersonal interactions in daily life are associated with subclinical depressive symptoms in a student sample: A prospective experience sampling study

Dysfunctional expectations and interpersonal problems are associated with depression, so we measured expected emotions towards interaction partners and compared them with actual emotions. We hypothesized that, between persons, individuals with higher subclinical depression would display stronger, more stable, and less accurate negative expectations. Within persons, we hypothesized that momentary negative expectations would predict subsequent negative affect. Fifty-three students completed 6 days of Experience Sampling, consisting of one morning expectation-assessment (9 am), three assessments on actual interpersonal emotions (1 pm, 5 pm, 9 pm), and six random affect-assessments. We regressed expected emotions, experienced emotions, expectation fluctuations, and expectation violations on subclinical depression. Using mixed model analyses, we further examined whether negative expectations preceded negative affect, and whether expectation violations preceded adjustments of expectations. Higher subclinical depression predicted more negative expectations. Within persons, worse-than-expected interpersonal interactions preceded negative affect whereas better-than-expected interactions preceded reductions of negative expectations. Despite problems with skewed data, our approach appears well-suited to examine interpersonal expectations in vivo.

How childhood maltreatment alters perception and cognition - the predictive processing account of borderline personality disorder

Borderline personality disorder (BPD) is a severe mental disorder, comprised of heterogeneous psychological and neurobiological pathologies. Here, we propose a predictive processing (PP) account of BPD to integrate these seemingly unrelated pathologies. In particular, we argue that the experience of childhood maltreatment, which is highly prevalent in BPD, leaves a developmental legacy with two facets: first, a coarse-grained, alexithymic model of self and others - leading to a rigidity and inflexibility concerning beliefs about self and others. Second, this developmental legacy leads to a loss of confidence or precision afforded beliefs about the consequences of social behavior. This results in an over reliance on sensory evidence and social feedback, with concomitant lability, impulsivity and hypersensitivity. In terms of PP, people with BPD show a distorted belief updating in response to new information with two opposing manifestations: rapid changes in beliefs and a lack of belief updating despite disconfirmatory evidence. This account of distorted information processing has the potential to explain both the instability (of affect, self-image, and interpersonal relationships) and the rigidity (of beliefs about self and others) which is typical of BPD. At the neurobiological level, we propose that enhanced levels of dopamine are associated with the increased integration of negative social feedback, and we also discuss the hypothesis of an impaired inhibitory control of the prefrontal cortex in the processing of negative social information. Our account may provide a new understanding not only of the clinical aspects of BPD, but also a unifying theory of the corresponding neurobiological pathologies. We conclude by outlining some directions for future research on the behavioral, neurobiological, and computational underpinnings of this model, and point to some clinical implications of it.

Testing Bayesian models of belief updating in the context of depressive symptomatology

OBJECTIVES

Predictive processing approaches to belief updating in depression propose that depression is related to more negative and more precise priors. Also, belief updating is assumed be negatively biased in comparison to normative Bayesian updating. There is a lack of efficient methods to mathematically model belief updating in depression.

METHODS

We validated a novel performance belief updating paradigm in a nonclinical sample (N = 133). Participants repeatedly participated in a non-self-related emotion recognition task and received false feedback. Effects of the feedback manipulation and differences in depressive symptoms on belief updating were analysed in Bayesian multilevel analyses.

RESULTS

Beliefs were successfully manipulated through the feedback provided. Depressive symptoms were associated with more negative updating than normative Bayesian updating but results were influenced by few cases. No evidence of biased change in beliefs or overly precise priors was found. Depressive symptoms were associated with more negative updating of generalised performance beliefs.

CONCLUSIONS

There was cautious support for negatively biased belief updating associated with depressive symptoms, especially for generalised beliefs. The content of the task may not be self-relevant enough to cause strong biases. Further explication of Bayesian models of depression and replication in clinical samples is needed.

Oversampled and undersolved: Depressive rumination from an active inference perspective

Rumination is a widely recognized cognitive deviation in depression. Despite the recognition, researchers have struggled to explain why patients cannot disengage from the process, although it depresses their mood and fails to lead to effective problem-solving. We rethink rumination as repetitive but unsuccessful problem-solving attempts. Appealing to an active inference account, we suggest that adaptive problem-solving is based on the generation, evaluation, and performance of candidate policies that increase an organism's knowledge of its environment. We argue that the problem-solving process is distorted during rumination. Specifically, rumination is understood as engaging in excessive yet unsuccessful oversampling of policy candidates that do not resolve uncertainty. Because candidates are sampled from policies that were selected in states resembling one's current state, "bad" starting points (e.g., depressed mood, physical inactivity) make the problem-solving process vulnerable for generating a ruminative "halting problem". This problem leads to high opportunity costs, learned helplessness and diminished overt behavior. Besides reviewing evidence for the conceptual paths of this model, we discuss its neurophysiological correlates and point towards clinical implications.

An Enactive-Ecological Model to Guide Patient-Centered Osteopathic Care

Osteopaths commonly face complexity and clinical uncertainty in their daily professional practice as primary contact practitioners. In order to effectively deal with complex clinical presentations, osteopaths need to possess well-developed clinical reasoning to understand the individual patient’s lived experience of pain and other symptoms and how their problem impacts their personhood and ability to engage with their world. We have recently proposed (En)active inference as an integrative framework for osteopathic care. The enactivist and active inference frameworks underpin our integrative hypothesis. Here, we present a clinically based interpretation of our integrative hypothesis by considering the ecological niche in which osteopathic care occurs. Active inference enables patients and practitioners to disambiguate each other’s mental states. The patients’ mental states are unobservable and must be inferred based on perceptual cues such as posture, body language, gaze direction and response to touch and hands-on care. A robust therapeutic alliance centred on cooperative communication and shared narratives and the appropriate and effective use of touch and hands-on care enable patients to contextualize their lived experiences. Touch and hands-on care enhance the therapeutic alliance, mental state alignment, and biobehavioural synchrony between patient and practitioner. Therefore, the osteopath–patient dyad provides mental state alignment and opportunities for ecological niche construction. Arguably, this can produce therapeutic experiences which reduce the prominence given to high-level prediction errors—and consequently, the top-down attentional focus on bottom-up sensory prediction errors, thus minimizing free energy. This commentary paper primarily aims to enable osteopaths to critically consider the value of this proposed framework in appreciating the complexities of delivering person-centred care.

How expectancy violations facilitate learning to cope with pain - An experimental approach

BACKGROUND

Expectations of painful sensations constitute a core feature of chronic pain. An important clinical question is whether such expectations are revised when disconfirming experiences are made (e.g., less pain than expected). This study examined how people adjust their pain expectations when the experience of decreasing pain is expected vs. unexpected.

METHODS

In a novel randomized between-subjects design, a subclinical sample of people who frequently experience pain was provided with painful thermal stimulations. Unbeknownst to participants, the temperature applied was decreased from trial to trial. Based on the experimental instructions provided, this experience of decreasing pain was expected in one condition (expectation-confirmation; n = 34), whereas it was unexpected in another (expectation-disconfirmation; n = 39).

RESULTS

Perceived pain intensity was lower in the expectation-confirmation condition than in the expectation-disconfirmation condition (p = .014, η_p² = 0.083). The expectation-confirmation condition also showed a greater adjustment of their pain expectations than the expectation-disconfirmation condition (p = .046, η_p² = 0.047). Across groups, large expectation violations (i.e., less pain than expected) were associated with increases in pain tolerance and the ability to cope with pain at a one-week follow-up.

CONCLUSIONS

In terms of assimilation, perceived pain intensity was shaped in the direction of pain expectations. The greater adjustment of expectations in the expectation-confirming condition is consistent with a confirmation bias in pain perception. Though participants who experienced large discrepancies between expected and experienced pain were hesitant to adjust their pain expectations immediately, expectation violations increased their ability to cope with pain one week later, suggesting some beneficial longer-term effects of expectation violations.

Unraveling Negative Expectations and Nocebo-Related Effects in Musculoskeletal Pain

This Perspective adapts the ViolEx Model, a framework validated in several clinical conditions, to better understand the role of expectations in the recovery and/or maintenance of musculoskeletal (MSK) pain. Here, particular attention is given to the condition in which dysfunctional expectations are maintained despite no longer being supported by confirmatory evidence (i.e., belief-lifting the arm leads to permanent tendon damage; evidence-after the patient lifts the arm no tendon damage occurs). While the ViolEx Model suggests that cognitive immunization strategies are responsible for the maintenance of dysfunctional expectations, we suggest that such phenomenon can also be understood from a Bayesian Brain perspective, according to which the level of precision of the priors (i.e., expectations) is the determinant factor accounting for the extent of priors' updating (i.e., we merge the two frameworks, suggesting that highly precise prior can lead to cognitive immunization responses). Importantly, this Perspective translates the theory behind these two frameworks into clinical suggestions. Precisely, it is argued that different strategies should be implemented when treating MSK pain patients, depending on the nature of their expectations (i.e., positive or negative and the level of their precision).

Let's Get Personal, Let's Get Physical: Approaching the Bodily Self in Clinical Interactions

Medicine usually looks at the body as a biochemical and physical apparatus - from a distant third-person perspective, with fragmented, reductionist positions, unidirectional causal models, and highly selective foci. Even psychiatrists and psychotherapists focus more and more on the brain as an organ, look at genes and colourful pictures. And just as biomedical medicine stares at physical and chemical facts and ignores the person, one could say that psychotherapy stares at personality, cognition, and behaviour and ignores the body. But the lowlands where being-a-person and having-a-body meetmatter a lot for becoming ill, staying, and getting well. What attitudes and what approaches can help us understand the bodily self? After very briefly summarizing current understandings of embodiment and enactivism, we will suggest some practical consequences for everyday clinical diagnostics.

[Body Experience and Body Interaction in Psychotherapeutic Diagnostics]

Since they are core features of many mental and psychosomatic disorders, disturbances of body experience and body interaction are relevant to understand and treat a particular patient. There are several body-related constructs, standardized psychometric instruments and experiments, focusing on single facets and following categorized evaluation. However, there is a lack of terminology and methods to individually and situationally understand and use body experience and body interaction in everyday clinical psychotherapeutic diagnostics. Based on clinical experience and a broad, topic-focused literature research, this discussion agenda delineates their core dimensions - bodily perception, body language, bodily changes, body-related narratives and actions, bodily resonance - and how to approach them by observation, mentalization, and relatedness.

Osteopathy and Mental Health: An Embodied, Predictive, and Interoceptive Framework

Globally, mental and musculoskeletal disorders present with high prevalence, disease burden, and comorbidity. In order to improve the quality of care for patients with persistent physical and comorbid mental health conditions, person-centered care approaches addressing psychosocial factors are currently advocated. Central to successful person-centered care is a multidisciplinary collaboration between mental health and musculoskeletal specialists underpinned by a robust therapeutic alliance. Such a collaborative approach might be found in osteopathy, which is typically utilized to treat patients with musculoskeletal disorders but may arguably also benefit mental health outcomes. However, research and practice exploring the reputed effect of osteopathy on patients with mental health problems lack a robust framework. In this hypothesis and theory article, we build upon research from embodied cognition, predictive coding, interoception, and osteopathy to propose an embodied, predictive and interoceptive framework that underpins osteopathic person-centered care for individuals with persistent physical and comorbid mental health problems. Based on the premise that, for example, chronic pain and comorbid depression are underlined by overly precise predictions or imprecise sensory information, we hypothesize that osteopathic treatment may generate strong interoceptive prediction errors that update the generative model underpinning the experience of pain and depression. Thus, physical and mental symptoms may be reduced through active and perceptual inference. We discuss how these theoretical perspectives can inform future research into osteopathy and mental health to reduce the burden of comorbid psychological factors in patients with persistent physical symptoms and support person-centered multidisciplinary care in mental health.

Does the Lightning Process Training Programme Reduce Chronic Fatigue in Adolescent and Young Adult Cancer Survivors? A Mixed-Methods Pilot Study

Simple Summary

Chronic fatigue is a common late adverse effect following oncological therapies. No effective treatments exist, although cognitive behaviour therapy has been reported to offer some benefits. The Lightning Process^® is a three-day educational training programme with a six-month follow-up comprising elements derived from cognitive behaviour therapy, neurolinguistic programming, and stress theory, which are presented in a condensed form. This pilot intervention study represents the first systematic account of the experience and perceived efficacy of the LP training programme in 13 adolescent and young adult cancer survivors treated for sarcoma or Hodgkin lymphoma. Statistically significant improvements were documented for all the patient-reported outcome measure (PROM) questionnaires comparing the pre- and post-intervention periods. The qualitative findings of the interviews corresponded well with the PROMs findings, as participants emphasised that they now experienced both less fatigue and explicit improvement in their energy level.

Abstract

Background: We report on a pilot intervention study exploring the efficacy of the Lightning Process^® training programme for reducing chronic fatigue and improving health-related quality of life in cancer survivors. Methods: 13 adolescent and young adult cancer survivors previously treated for sarcoma or Hodgkin lymphoma were enrolled. A mixed-methods approach was applied. This involved the use of five validated patient-reported outcome measure (PROM) questionnaires at baseline and the three- and six-month follow-up points to obtain quantitative data. Semi-structured interviews were conducted after the intervention with emphasis on the participants’ experiences and outcomes. A reflexive thematic analysis was applied to the transcripts. Results: A significant reduction (p < 0.001) in the total fatigue score from baseline to the three- and six-month follow-up points was documented. The correlation coefficients between the various PROMs at baseline and the six-month follow-up point indicated considerable overlap between the measures. The qualitative findings of the interviews corresponded well with the PROM findings. Most participants experienced both less fatigue and explicit improvement in their energy level. The aspects of the intervention found to be particularly helpful were the theoretical rationale and the coping techniques mediated. Conclusion: These encouraging results here reported should be of interest to the general oncological community, although they require confirmation through a larger and controlled study.

Cognitive Behavioral Therapy of Patients with Somatic Symptoms-Diagnostic and Therapeutic Difficulties

In every somatic disease we can find a psychological element, just as it is not uncommon for numerous physical symptoms to occur in a mental disease. Nowadays, the patient is no longer just the “owner” of the sick organ but is considered and treated as a “whole”. The interpenetration of somatic manifestations with mental health problems forces patients who experience subjective suffering, including mental suffering, from current symptoms to visit specialists from different fields of medicine, and their treatment does not bring about any improvement. Cognitive behavioral psychotherapy (CBT) is one form of therapy that attempts to respond to the needs of an increasing—in recent years—number of patients who demonstrate somatic disorders of a multifaceted nature. The co-occurrence of physical and mental disorders repeatedly makes it impossible to determine which symptoms were the cause and which were the effect; hence, it is difficult to establish clear boundaries between the categories of these disorders and diseases. The therapist, to whom the patient with somatic diseases is eventually referred, may be faced with a diagnostic dilemma, the solution of which will give direction to further psychotherapeutic work. The common feature of this group of patients is a strong focus on physical ailments, while omitting or almost completely ignoring the psychological factors involved. The purpose of this paper is to present the causally diverse circumstances in which a patient with physical symptoms needs diagnosis and therapeutic support from the perspective of a cognitive behavioral approach.

What Does CATS Have to Do With Cancer? The Cognitive Activation Theory of Stress (CATS) Forms the SURGE Model of Chronic Post-surgical Pain in Women With Breast Cancer

Chronic post-surgical pain (CPSP) represents a highly prevalent and significant clinical problem. Both major and minor surgeries entail risks of developing CPSP, and cancer-related surgery is no exception. As an example, more than 40% of women undergoing breast cancer surgery struggle with CPSP years after surgery. While we do not fully understand the pathophysiology of CPSP, we know it is multifaceted with biological, social, and psychological factors contributing. The aim of this review is to advocate for the role of response outcome expectancies in the development of CPSP following breast cancer surgery. We propose the Cognitive Activation Theory of Stress (CATS) as an applicable theoretical framework detailing the potential role of cortisol regulation, inflammation, and inflammatory-induced sickness behavior in CPSP. Drawing on learning theory and activation theory, CATS offers psychobiological explanations for the relationship between stress and health, where acquired expectancies are crucial in determining the stress response and health outcomes. Based on existing knowledge about risk factors for CPSP, and in line with the CATS position, we propose the SURGEry outcome expectancy (SURGE) model of CPSP. According to SURGE, expectancies impact stress physiology, inflammation, and fear-based learning influencing the development and persistence of CPSP. SURGE further proposes that generalized response outcome expectancies drive adaptive or maladaptive stress responses in the time around surgery, where coping dampens the stress response, while helplessness and hopelessness sustains it. A sustained stress response may contribute to central sensitization, alterations in functional brain networks and excessive fear-based learning. This sets the stage for a prolonged state of inflammatory-induced sickness behavior - potentially driving and maintaining CPSP. Finally, as psychological factors are modifiable, robust and potent predictors of CPSP, we suggest hypnosis as an effective intervention strategy targeting response outcome expectancies. We here argue that presurgical clinical hypnosis has the potential of preventing CPSP in women with breast cancer.

Functional pain disorders - more than nociplastic pain

BACKGROUND

Nociplastic pain has been recently introduced as a third mechanistic descriptor of pain arising primarily from alterations of neural processing, in contrast to pain due to tissue damage leading to nociceptor activation (nociceptive) or due to lesion or disease of the somatosensory nervous system (neuropathic). It is characterized by hyperalgesia and allodynia, inconsistency and reversibility, as well as dynamic cross-system interactions with biological and psychobehavioral factors. Along with this renewed understanding, functional pain disorders, also classified as chronic primary pain, are being reframed as biopsychosocial conditions that benefit from multimodal treatment.

OBJECTIVE

To summarize the current understanding of nociplastic pain and functional pain disorders, with a focus on conditions that are common in neurology practice.

METHODS

This was a narrative literature review.

RESULTS

Chronic back pain, fibromyalgia syndrome and complex regional pain syndrome are best understood within a biopsychosocial framework of pain perception that considers structural factors (predispositions and sequelae) and psychobehavioral mechanisms. Although pain is often the primary complaint, it should not be the only focus of treatment, as accompanying symptoms such as sleep or mood problems can significantly impact quality of life and offer useful leverage points for multimodal treatment. Analgesic pharmacotherapy is rarely helpful on its own, and should always be imbedded in a multidisciplinary setting.

Development of an eHealth programme for self-management of persistent physical symptoms: a qualitative study on user needs in general practice

Background

Persistent physical symptoms (PPS) are estimated to be present in 17% of patients in general practice. Hence, general practitioners (GPs) play a key role in both the diagnostic assessment and the management of PPS. However, research indicates a need to improve their strategies to support self-help in patients, and eHealth tools may serve as an opportunity. This study aimed to explore patients’ and GPs’ needs related to self-management of PPS. The study was designed to inform the future development of eHealth interventions in this field.

Methods

This qualitative study was based on 20 semi-structured interviews (6 GPs and 14 patients with PPS). Interviews were audiotaped, transcribed verbatim and analysed through a five-step thematic analysis approach. First, we conducted an inductive analysis to identify and explore emerging subthemes. Second, using a deductive mapping strategy, we categorised the derived subthemes according to the COM-B behaviour change model and its three domains: capability, opportunity and motivation.

Results

We identified eleven subthemes in the patient interviews and seven subthemes in the GP interviews. Several unmet needs emerged. First, we identified a need to consider PPS early in the illness trajectory by taking a bio-psycho-social approach. Second, both patients and GPs need better skills to manage uncertainty. Third, hope is important for the patients. Fourth, patients need guidance from their GP in how to self-manage their PPS.

Conclusions

This study provides important insight into key issues and needs related to capability, opportunity and motivation that should be addressed in the design of future eHealth self-management interventions targeting patients with PPS in general practice in order to support and improve care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01380-5.

When Beliefs Face Reality: An Integrative Review of Belief Updating in Mental Health and Illness

Belief updating is a relatively nascent field of research that examines how people adjust their beliefs in light of new evidence. So far, belief updating has been investigated in partly unrelated lines of research from different psychological disciplines. In this article, we aim to integrate these disparate lines of research. After presenting some prominent theoretical frameworks and experimental designs that have been used for the study of belief updating, we review how healthy people and people with mental disorders update their beliefs after receiving new information that supports or challenges their views. Available evidence suggests that both healthy people and people with particular mental disorders are prone to certain biases when updating their beliefs, although the nature of the respective biases varies considerably and depends on several factors. Anomalies in belief updating are discussed in terms of both new insights into the psychopathology of various mental disorders and societal implications, such as irreconcilable political and societal controversies due to the failure to take information into account that disconfirms one’s own view. We conclude by proposing a novel integrative model of belief updating and derive directions for future research.

Rethinking post-traumatic stress disorder - A predictive processing perspective

Predictive processing has become a popular framework in neuroscience and computational psychiatry, where it has provided a new understanding of various mental disorders. Here, we apply the predictive processing account to post-traumatic stress disorder (PTSD). We argue that the experience of a traumatic event in Bayesian terms can be understood as a perceptual hypothesis that is subsequently given a very high a-priori likelihood due to its (life-) threatening significance; thus, this hypothesis is re-selected although it does not fit the actual sensory input. Based on this account, we re-conceptualise the symptom clusters of PTSD through the lens of a predictive processing model. We particularly focus on re-experiencing symptoms as the hallmark symptoms of PTSD, and discuss the occurrence of flashbacks in terms of perceptual and interoceptive inference. This account provides not only a new understanding of the clinical profile of PTSD, but also a unifying framework for the corresponding pathologies at the neurobiological level. Finally, we derive directions for future research and discuss implications for psychological and pharmacological interventions.