Biased interpretations of ambiguous bodily threat information in adolescents with chronic pain

Attachment in Young Adults With Chronic Pain: The Mediating Role of Cognitive Appraisals in the Relationship Between Attachment Security, Pain Coping and Functioning

BACKGROUND

Attachment styles can influence how individuals perceive and cope with chronic pain. This study examined the relationships between attachment security, pain coping and functioning in young adults with chronic pain, focusing on the mediating role of cognitive appraisals.

METHODS

This cross-sectional study included 206 young adults attending university aged 17-29 with chronic pain (Mage = 19.24, SD = 2.03) and 346 without pain (Mage = 19.11, SD = 1.79). Participants completed measures assessing pain characteristics, attachment security, pain coping strategies, physical and social functioning and cognitive appraisals relating to bodily and social threat bias and pain catastrophising. SPSS PROCESS macro was used to test mediational hypotheses.

RESULTS

Young adults with chronic pain had greater insecure attachment than controls (Mann-Whitney U = 41639.50, p < 0.001). Insecure attachment was significantly associated with poorer solution-focused coping and social functioning (r = -0.330 and - 0.355 respectively), and increased emotion-focused avoidance (r = 0.317). Social threat bias partially mediated the effects of attachment security on emotion-focused avoidance and social functioning. Pain catastrophising partially mediated the effects of attachment security on solution-focused coping and social functioning, and fully mediated its effects on emotion-focused avoidance. An indirect effect of attachment security on reframing and distraction was found via social threat and pain catastrophising.

CONCLUSIONS

Insecure attachment is heightened in young adults with chronic pain and may contribute to poorer pain coping and social functioning through cognitive appraisals, specifically social threat and pain catastrophising. These may be useful targets for intervention.

Interpretation bias and its relationship with pain: a systematic review and meta-analysis

ABSTRACT

The aim of this review was to systematically review and meta-analyse evidence for the presence of interpretation bias in pain and to establish the likely role of interpretation bias in chronic pain. The primary questions were whether people experiencing pain showed a greater interpretation bias than people without pain and whether interpretation bias was associated with pain outcomes. We were also interested in evaluating existing longitudinal and intervention research, which could inform interpretation bias as a causal mechanism and/or treatment target in pain. A total of 33 studies across 31 articles were identified (combined n = 4842). People with chronic pain showed a greater interpretation bias than people without pain, with a moderate effect (g = 0.602). This effect was even more pronounced when interpretation bias was measured with the word association task, reaching a large effect size (g = 0.899). Interpretation bias was associated with degree of pain interference, pain catastrophising, and less reliably with pain severity, but not with experimental pain outcomes. Longitudinal studies (k = 3) were mixed as to whether interpretation bias predicted subsequent pain. Whereas, intervention studies (k = 3) showed that interpretation bias could be modified and, for chronic pain, led to improved pain outcomes. Overall, data show that interpretation biases are robust among those with chronic pain compared with those without and are associated with pain interference. There is emerging evidence that interpretation biases are a treatment target that can be modified for improved pain outcomes.

Gamified Web-Delivered Attentional Bias Modification Training for Adults With Chronic Pain: Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Attentional bias to pain-related information has been implicated in pain chronicity. To date, research investigating attentional bias modification training (ABMT) procedures in people with chronic pain has found variable success, perhaps because training paradigms are typically repetitive and monotonous, which could negatively affect engagement and adherence. Increasing engagement through the gamification (ie, the use of game elements) of ABMT may provide the opportunity to overcome some of these barriers. However, ABMT studies applied to the chronic pain field have not yet incorporated gamification elements.

OBJECTIVE

This study aimed to investigate the effects of a gamified web-delivered ABMT intervention in a sample of adults with chronic pain via a randomized, double-blind, placebo-controlled trial.

METHODS

A final sample of 129 adults with chronic musculoskeletal pain, recruited from clinical (hospital outpatient waiting list) and nonclinical (wider community) settings, were included in this randomized, double-blind, placebo-controlled, 3-arm trial. Participants were randomly assigned to complete 6 web-based sessions of nongamified standard ABMT (n=43), gamified ABMT (n=41), or a control condition (nongamified sham ABMT; n=45) over a period of 3 weeks. Active ABMT conditions trained attention away from pain-related words. The gamified task included a combination of 5 game elements. Participant outcomes were assessed before training, during training, immediately after training, and at 1-month follow-up. Primary outcomes included self-reported and behavioral engagement, pain intensity, and pain interference. Secondary outcomes included anxiety, depression, cognitive biases, and perceived improvement.

RESULTS

Results of the linear mixed model analyses suggest that across all conditions, there was an overall small to medium decline in self-reported task-related engagement between sessions 1 and 2 (P<.001; Cohen d=0.257; 95% CI 0.13-0.39), sessions 1 and 3 (P<.001; Cohen d=0.368; 95% CI 0.23-0.50), sessions 1 and 4 (P<.001; Cohen d=0.473; 95% CI 0.34-0.61), sessions 1 and 5 (P<.001; Cohen d=0.488; 95% CI 0.35-0.63), and sessions 1 and 6 (P<.001; Cohen d=0.596; 95% CI 0.46-0.73). There was also an overall small decrease in depressive symptoms from baseline to posttraining assessment (P=.007; Cohen d=0.180; 95% CI 0.05-0.31) and in pain intensity (P=.008; Cohen d=0.180; 95% CI 0.05-0.31) and pain interference (P<.001; Cohen d=0.237; 95% CI 0.10-0.37) from baseline to follow-up assessment. However, no differential effects were observed over time between the 3 conditions on measures of engagement, pain intensity, pain interference, attentional bias, anxiety, depression, interpretation bias, or perceived improvement (all P values>.05).

CONCLUSIONS

These findings suggest that gamification, in this context, was not effective at enhancing engagement, and they do not support the widespread clinical use of web-delivered ABMT in treating individuals with chronic musculoskeletal pain. The implications of these findings are discussed, and future directions for research are suggested.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000803998; https://anzctr.org.au/ACTRN12620000803998.aspx.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/32359.

Cognitive Biases and Insomnia Symptoms in People With and Without Chronic Pain

Chronic pain and insomnia symptoms are highly comorbid; however, the psychological mechanisms driving this comorbidity are not well understood. The aim of the present study was to assess whether 2 cognitive biases that occur separately in chronic pain and insomnia, that is, interpretation bias and attentional bias, are heightened in people with comorbid chronic pain and elevated insomnia symptoms. A final sample of N = 109 people with chronic pain and N = 79 people without pain who varied in insomnia symptoms were recruited through Prolific Academic to complete this cross-sectional study. Participants completed measures of sleep and pain-related interpretation bias (ambiguous sentences task) and attentional bias (dot-probe task), as well as questionnaires assessing insomnia symptoms, pain symptoms, and general psychological symptoms. We found an interaction between pain status and insomnia symptoms for sleep-related interpretation bias. That is, people with chronic pain showed greater sleep-related interpretation bias than those without pain, but only when insomnia symptoms were also elevated. This interaction did not extend to pain interpretation bias or attentional bias, although we did find an elevated pain interpretation bias in people with chronic pain compared to pain-free individuals. We also found that both pain and sleep-related interpretation bias were associated with depression symptoms, suggesting that interpretation bias could potentially drive a trimorbidity of chronic pain, insomnia, and depression. Taken together, these findings suggest promise for the role of interpretation bias in the mutual maintenance of chronic pain and insomnia symptoms and the importance of also considering depression. PERSPECTIVE: This article presents data on the cognitive biases that are present in chronic pain, and that are associated with increased insomnia symptoms. Identifying such cognitive biases could help in explaining the high comorbidity between chronic pain and insomnia, leading to more effective and targeted treatments.

Interpretation bias in endometriosis-related pain

ABSTRACT

Endometriosis-related pain has been predominantly medically managed, which has hindered understanding of psychological factors involved in these pain experiences. Models of chronic pain highlight the biased interpretation of ambiguous information as health threat related (interpretation bias) as an important process in the development and maintenance of chronic pain. Whether interpretation bias may also be similarly implicated in endometriosis-related pain is unclear. The current study aimed to address this gap in the literature by (1) comparing interpretation biases between a sample of participants with endometriosis and a control sample of participants without medical conditions and pain, (2) exploring relationships between interpretation bias and endometriosis-related pain outcomes, and (3) exploring whether interpretation bias moderated the relationship between endometriosis-related pain severity and pain interference. The endometriosis and healthy control samples comprised 873 and 197 participants, respectively. Participants completed online surveys assessing demographics, interpretation bias, and pain-related outcomes. Analyses revealed that interpretation bias was significantly stronger among individuals with endometriosis relative to controls, with a large effect size. Within the endometriosis sample, interpretation bias was significantly associated with increases in pain-related interference, however, interpretation bias was not associated with any other pain outcomes and did not moderate the relationship between pain severity and pain interference. This study is the first to evidence biased interpretation styles among individuals with endometriosis and to show this bias is associated with pain interference. Whether interpretation bias varies over time and whether this bias can be modified through scalable and accessible interventions to alleviate pain-related interference are avenues for future research.

Testing a Combined Cognitive Bias Hypothesis of Pain and Pain-related Worry in Young People

Cognitive factors are thought to contribute and maintain pain experiences in young people. However, most of these factors have been assessed in isolation. Considering more than 1 cognitive factor could increase explanatory power and identify multiple targets for intervention. Here, we tested a Combined Cognitive Bias Hypothesis (CCBH) that suggests information-processing factors associate with each other and exert either additive and/or interactive influences on pain outcomes. We conducted secondary analysis of data from 243 adolescents aged 16 to 19 years, who had completed a task measuring pain-related attention control impairments (emotion-priming visual search task) and a task measuring biased interpretations towards threatening cues (Adolescent Interpretation of Bodily Threat task). These young people also completed measures of recent pain experiences and pain catastrophizing, which served as primary and secondary outcomes, respectively. Regression analyses revealed that difficulties with attention control (following presentation of pain-related stimuli) and tendencies to endorse threatening interpretations of ambiguous situations had significant additive effects on both pain outcomes. However, correlations between these factors were non-significant. They also did not interact to influence pain outcomes. These findings require replication in broader age ranges and clinical samples but potentially suggest that, measuring multiple cognitive factors increases explanatory power of youth pain outcomes. PERSPECTIVE: Weak attention control following exposure to pain cues and tendencies to endorse threat interpretations, uniquely and additively associate with self-reported pain experiences and pain catastrophizing in community youth. Measuring several cognitive factors simultaneously could improve our ability to explain pain outcomes in adolescent populations.

Pain Expectancy and Positive Affect Mediate the day-to-day Association Between Objectively Measured Sleep and Pain Severity Among Women With Temporomandibular Disorder

The majority of individuals with temporomandibular disorders (TMD) experience sleep disturbance, which can maintain and exacerbate chronic pain. However, the factors underlying the sleep-pain link have not been fully elucidated, especially beyond the laboratory. Sleep deprivation can induce threat interpretation bias, as well as impairment in positive affective functioning. Using both actigraphy and daily diaries, we examined whether morning pain expectancy and positive affect mediate the association between previous night's sleep disturbance and next-day overall pain severity. Total sleep time (TST) was selected as the primary measure of sleep. The sample included 144 women (mean age = 36 [SD = 11.1]) with TMD who displayed at least subclinical insomnia. Sleep was assessed for 14 days using actigraphy which was validated by concurrent sleep diaries. Daily diary assessments of pain-related experiences and affective states were conducted twice per day (ie, once upon participants' waking and the other prior to going to sleep) for the same 14-day period. Multilevel structural equation modeling revealed that both morning pain expectancy (95% CI: -.0004, -.00003) and positive affect (95% CI: -.0005, -.000001) mediated the association between previous night's TST and next-day's overall pain severity, such that shorter previous night TST was associated with higher next-morning pain expectancy and lower positive affect, which in turn were associated with a greater level of next-day's overall pain severity while controlling for morning pain severity. Reducing exaggerated daily pain expectancy and up-regulating positive affect may be important intervention targets for disengaging the sleep-pain link among individuals with co-occurring TMD and sleep disturbance. PERSPECTIVE: The daily link between previous night sleep duration and next day pain severity is mediated by morning pain expectancy and positive affect among women with temporomandibular disorder and sleep disturbance. Reducing pain expectancy and increasing positive affect may serve an important role in improving self-management of chronic pain.

Gamified Web-Delivered Attentional Bias Modification Training for Adults With Chronic Pain: Protocol for a Randomized, Double-blind, Placebo-Controlled Trial

Background

To date, research has found variable success in using attentional bias modification training (ABMT) procedures in pain samples. Several factors could contribute to these mixed findings, including boredom and low motivation. Indeed, training paradigms are repetitive, which can lead to disengagement and high dropout rates. A potential approach to overcoming some of these barriers is to attempt to increase motivation and engagement through gamification (ie, the use of game elements) of this procedure. To date, research has yet to explore the gamified format of ABMT for chronic pain and its potential for the transfer of benefits.

Objective

The aim of this study is to investigate the effects of a gamified web-delivered ABMT intervention in a sample of adults with chronic pain via a randomized, double-blind, placebo-controlled trial.

Methods

A total of 120 adults with chronic musculoskeletal pain, recruited from clinical (hospital outpatient waiting list) and nonclinical (wider community) settings, will be included in this randomized, double-blind, placebo-controlled, 3-arm trial. Participants will be randomly assigned to complete 6 web-based sessions of dot-probe nongamified sham control ABMT, nongamified standard ABMT, or gamified ABMT across a period of 3 weeks. Active ABMT conditions will aim to train attention away from pain-relevant words. Participant outcomes will be assessed at pretraining, during training, immediately after training, and at the 1-month follow-up. Primary outcomes include pain intensity, pain interference, and behavioral and self-reported engagement. Secondary outcomes include attentional bias for pain, anxiety, depression, interpretation bias for pain, and perceived improvement.

Results

The ethical aspects of this research project have been approved by the human research ethics committees of the Royal Brisbane and Women’s Hospital (HREC/2020/QRBW/61743) and Queensland University of Technology (2000000395). Study recruitment commenced in August 2021 and is ongoing. Data collection and analysis are expected to be concluded by October 2022 and January 2023, respectively.

Conclusions

This trial will be the first to evaluate the effects of gamification techniques in a pain ABMT intervention. The findings will provide important information on the potential therapeutic benefits of gamified pain ABMT programs, shed light on the motivational influences of certain game elements in the context of pain, and advance our understanding of chronic pain.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620000803998; https://anzctr.org.au/ACTRN12620000803998.aspx

International Registered Report Identifier (IRRID)

PRR1-10.2196/32359

Interpretation Biases in Pain: Validation of Two New Stimulus Sets

Adults with chronic pain interpret ambiguous information in a pain and illness related fashion. However, limitations have been highlighted with traditional experimental paradigms used to measure interpretation biases. Whilst ambiguous scenarios have been developed to measure interpretation biases in adolescents with pain, no scenario sets exist for use with adults. Therefore, the present study: (i) sought to validate a range of ambiguous scenarios suitable for measuring interpretation biases in adults, whilst also allowing for two response formats (forced-choice and free response); and (ii) investigate paradigm efficacy, by assessing the effects of recent pain experiences on task responding. A novel ambiguous scenarios task was administered to adults (N = 241). Participants were presented with 62 ambiguous scenarios comprising 42 that could be interpreted in a pain/pain-illness or non-pain/non-pain illness manner: and 20 control scenarios. Participants generated their own solutions to each scenario (Word Generation Task), then rated how likely they would be to use two researcher-generated solutions to complete each scenario (Likelihood Ratings Task). Participants also rated their subjective experiences of pain in the last 3 months. Tests of reliability, including inter-rater agreement and internal consistency, produced two ambiguous scenario stimulus sets containing 18 and 20 scenarios, respectively. Further analyses revealed adults who reported more recent pain experiences were more likely to endorse the pain/pain-illness solutions in the Likelihood Ratings Task. This study provides two new stimulus sets for use with adults (including control items) in pain research and/or interventions. Results also provide evidence for a negative endorsement bias in adults.

The effects of attentional and interpretation biases on later pain outcomes among younger and older adults: A prospective study

BACKGROUND

Studies examining the effect of biased cognitions on later pain outcomes have primarily focused on attentional biases, leaving the role of interpretation biases largely unexplored. Also, few studies have examined pain-related cognitive biases in elderly persons. The current study aims to fill these research gaps.

METHODS

Younger and older adults with and without chronic pain (N = 126) completed an interpretation bias task and a free-viewing task of injury and neutral scenes at baseline. Participants' pain intensity and disability were assessed at baseline and at a 6-month follow-up. A machine-learning data-driven approach to analysing eye movement data was adopted.

RESULTS

Eye movement analyses revealed two common attentional pattern subgroups for scene-viewing: an "explorative" group and a "focused" group. At baseline, participants with chronic pain endorsed more injury-/illness-related interpretations compared to pain-free controls, but they did not differ in eye movements on scene images. Older adults interpreted illness-related scenarios more negatively compared to younger adults, but there was also no difference in eye movements between age groups. Moreover, negative interpretation biases were associated with baseline but not follow-up pain disability, whereas a focused gaze tendency for injury scenes was associated with follow-up but not baseline pain disability. Additionally, there was an indirect effect of interpretation biases on pain disability 6 months later through attentional bias for pain-related images.

CONCLUSIONS

The present study provided evidence for pain status and age group differences in injury-/illness-related interpretation biases. Results also revealed distinct roles of interpretation and attentional biases in pain chronicity.

SIGNIFICANCE

Adults with chronic pain endorsed more injury-/illness-related interpretations than pain-free controls. Older adults endorsed more illness interpretations than younger adults. A more negative interpretation bias indirectly predicted pain disability 6 months later through hypervigilance towards pain.

Examining attentional biases, interpretation biases, and attentional control in people with and without chronic pain

ABSTRACT

Psychological models of chronic pain (CP) highlight cognitive-processing biases (ie, attentional biases, interpretation biases, and attentional control) as pivotal processes that uniquely and synergistically impact the development and maintenance of CP. Very few studies explore multiple cognitive biases, and no studies have examined these 3 processes together in a CP sample. Furthermore, there is a lack of research investigating the relationship between these cognitive processes and pain-relevant variables (eg, pain intensity and pain catastrophising). The current study aimed to (1) compare attentional biases, interpretation biases, and attentional control in people with and without CP, (2) explore their interrelationships, and (3) explore their association with pain-related variables. Seventy-four participants with CP and 66 without pain volunteered. Participants completed a visual scanning task with eye tracking, a recognition task, and a flanker task. Traditional and Bayesian analysis indicated no effect of pain status on cognitive-processing biases. All participants, regardless of pain status, demonstrated attentional biases towards pain on some indices of early and late attention, but not interpretation bias or attentional control. There was weak evidence of associations between attentional biases, interpretation biases, and attentional control. Pain intensity was significantly correlated with interpretation biases, and follow-up analyses revealed people with high pain intensity demonstrated an interpretation bias towards pain significantly more than those with low pain intensity. Findings suggest that attentional biases towards pain are ubiquitous, but for people with moderate-to-severe pain, interpretation biases may have a role worthy of further research.

Are biased interpretations of ambiguous social and non-social situations a precursor, consequence or maintenance factor of youth loneliness?

Loneliness is common in youth, with suggestions that these negative emotions confer vulnerability for anxiety and depression. Here, we investigated for the first time whether, consistent with psychological models of loneliness, biased interpretations of social situations could prospectively predict loneliness in youth. 104 young people completed measures of loneliness and interpretations of ambiguous social and non-social (bodily or health-related) situations at three time-points with intervals of three months between each. As government-imposed social distancing measures (to control the COVID-19 outbreak) occurred between Times 2 and 3 (but not between Times 1 and 2), this enabled us to assess whether restricted social activity could provoke greater predictive power of biased interpretational styles on loneliness. Using cross-lagged panel models, we showed that after estimating paths representing within-time across-variable ("concurrent") paths and across-time within-variable ("stability") paths, there were no significant cross-lag 'causal' paths between earlier interpretational style and later loneliness. Between Time 2 and 3, we demonstrated a significant cross-lag 'consequential' path between earlier loneliness and later threatening interpretations of social situations, but this became non-significant after controlling for concurrent anxiety and depression. Biased interpretational style may reflect a concurrent maintenance factor of youth loneliness.

Associations between biased threat interpretations, fear and avoidance of pain and pain-linked disability in adolescent chronic pain patients

BACKGROUND

Biased interpretations of ambiguous bodily threat situations characterize youth with chronic pain, and have been associated with functional disability for this population. Despite predictions by the fear-avoidance model of chronic pain, that fear and avoidance of pain explain the association between threat perceptions and disability, this has not yet been explored in youth with chronic pain. This study aimed to address this gap by investigating these proposed relationships, in addition to the association between bodily threat interpretations and daily aspects of disability (as well as social, and emotional impairments).

METHOD

Sixty-eight adolescents aged 11-18 years old with a clinical diagnosis of chronic pain completed an extended version of the Adolescent Interpretations of Bodily Threat task to assess interpretations of bodily and social threat situations, alongside measures of disability and fear and avoidance of pain.

RESULTS

Using mediation analysis, fear and avoidance of pain statistically accounted for the relationship between negative bodily threat interpretations and functional disability. Significant associations were also demonstrated between negative bodily threat interpretations and adolescent-reported impairments in daily, emotional and social impairments. Data revealed a significant relationship between negative social interpretations and daily functional disability.

CONCLUSIONS

Findings indicate the clinical relevance of bodily and social threat interpretations, and fear and avoidance of pain, for this population and raise further questions regarding the content-specificity of threat interpretations.

SIGNIFICANCE

Psychological theories of pain-associated impact and disability point to fear and avoidance of pain, as well as information-processing biases. Here, we present novel data showing the clinical relevance of bodily and social threat interpretations in explaining pain-related disability amongst youth with chronic pain, potentially by shaping fear and avoidance of pain. Longitudinal designs will be required to assess these temporally sensitive mediation pathways.

Evaluation of the Factor Structure and Content Specificity of the Interpretation Bias Task (IBT)

Background

Theories suggest that interpretation biases play a role in the aetiology of a range of psychopathology including depression, anxiety and psychosis. We evaluate the psychometric properties of an adapted version of an ambiguous scenario task (i.e., Interpretation Bias Task [IBT]) that assesses benign and negative interpretations in four domains: immediate bodily injury; long-term illness; social rejection; and, performance failure.

Methods

The factor structure of the IBT was evaluated in a student sample (N = 237) in Study 1, and subsequently confirmed in a community sample with a wider age range (N = 1103) in Study 2. Correlations between interpretation biases and health and social anxiety symptoms were tested in both studies.

Results

The four IBT domains were differentiable and each was represented by two factors (i.e., benign vs. negative). In Study 1, higher health anxiety was characterised by fewer benign interpretations for injury- and illness-related scenarios, whereas higher social anxiety was associated with more negative and fewer benign interpretations for social rejection and performance failure scenarios. Correlational results were replicated in Study 2 for social anxiety, but not health anxiety.

Conclusions

The IBT is suitable for measuring interpretation biases in Asian adults. The content specificity of interpretation biases was partially supported.

Interpretation biases and visual attention in the processing of ambiguous information in chronic pain

BACKGROUND

Theories propose that interpretation biases and attentional biases might account for the maintenance of chronic pain symptoms, but the interactions between these two forms of biases in the context of chronic pain are understudied.

METHODS

To fill this gap, 63 participants (40 females) with and without chronic pain completed an interpretation bias task that measures participants' interpretation styles in ambiguous scenarios and a novel eye-tracking task where participants freely viewed neutral faces that were given ambiguous pain/health-related labels (i.e. 'doctor', 'patient' and 'healthy people'). Eye movements were analysed with the Hidden Markov Models (EMHMM) approach, a machine-learning data-driven method that clusters people's eye movements into different strategy subgroups.

RESULTS

Adults with chronic pain endorsed more negative interpretations for scenarios related to immediate bodily injury and long-term illness than healthy controls, but they did not differ significantly in terms of their eye movements on ambiguous faces. Across groups, people who interpreted illness-related scenarios in a more negative way also focused more on the nose region and less on the eye region when looking at patients' and healthy people's faces and, to a lesser extent, doctors' faces. This association between interpretive and attentional processing was particularly apparent in participants with chronic pain.

CONCLUSIONS

In summary, the present study provided evidence for the interplay between multiple forms of cognitive biases. Future studies should investigate whether this interaction might influence subsequent functioning in people with chronic pain.

The relation between parental chronic pain, pain-related attention and interpretation biases in pain-free adolescents

BACKGROUND

Children of chronic pain patients run greater risk for developing chronic pain themselves. Exposure to chronic pain of the parent might install cognitive (e.g., pain catastrophizing, interpretation and attentional bias) and affective (e.g., pain anxiety) vulnerability which increase the risk for the development of chronic pain complaints in offspring. This study examines whether pain-free offspring of parents with chronic pain complaints make more health-threatening interpretations and display a stronger pain-related attentional bias compared to the offspring of pain-free parents. We furthermore examined differences between both groups on pain catastrophizing, pain anxiety and somatic symptoms and explored the relations between parental pain catastrophizing and aforementioned pain vulnerability measures in offspring.

METHODS

Offspring of parents with chronic pain complaints (n = 24) and pain-free parents (n = 27) completed measures of attentional bias (i.e., pictorial dot probe), interpretation bias (i.e., ambiguous word association task), pain catastrophizing, pain anxiety and somatic symptoms. Parents completed measures of pain catastrophizing and psychological distress.

RESULTS

No differences between offspring of parents with and without pain complaints were observed on pain catastrophizing, pain anxiety and somatic symptoms. Both groups of healthy adolescents predominantly showed benign, non-health-threatening interpretations. Children of pain-free parents showed an attention bias for pain stimuli, while offspring of parents with pain complaints showed no such bias.

CONCLUSIONS

Future research is needed to further elucidate the precise role of parental pain in the development of pain-related biases and the significance of these biases in the onset and/or maintenance of a chronic pain condition in children and adolescents.

SIGNIFICANCE

Parental chronic pain may install psychological vulnerability for developing chronic pain and associated complaints in offspring. This study did not show differences in pain-directed attentional and interpretation bias between offspring of parents with chronic pain complaints and offspring of pain-free parents. Further (longitudinal) research is needed to elucidate the precise role of parental pain factors in the development of pain-related vulnerability in offspring of chronic pain parents, thereby identifying important targets for the prevention and early intervention of chronic pain.

Catastrophizing, pain, and functional outcomes for children with chronic pain: a meta-analytic review

Pediatric chronic pain is associated with numerous negative outcomes including increased physical disability, increased rates of depression and anxiety, and decreased quality of life (QOL). Pain catastrophizing-broadly conceptualized as including rumination, magnification, and helplessness cognitions surrounding one's pain-has been linked with poor functional outcomes in children with chronic pain. Pain catastrophizing in pediatric chronic pain is often considered a key factor on which to focus treatment efforts. However, absent a systematic review that integrates the relevant literature, this call for routine assessment and targeted treatment may be premature. This study aimed to: (1) meta-analytically quantify the relationship between catastrophizing and pain and functional/psychosocial outcomes (functional disability/physical functioning, anxiety, depression, and QOL) in children with chronic pain, and (2) examine potential moderators of these relationships. Using a random-effects model, a total of 111 effect sizes from 38 studies were analyzed. Effect sizes ranged from medium to large, with anxiety, depression, and QOL demonstrating a strong association with catastrophizing. Pain intensity and physical disability had a moderate association with catastrophizing. These relationships were robust, minimizing potential publication bias. None of the examined moderators were significant. The strong relationships found between catastrophizing and anxiety, depression, and QOL suggest that successfully intervening on catastrophizing could have far reaching implications in improving pain outcomes in pediatric chronic pain.

Automatic processes and self-regulation of illness

Research on the Commonsense Self-Regulation Model has emphasised reflective/conscious perceptual processes regarding illness threat (beliefs about symptoms, consequences, timeline, and curability) in predicting and changing coping behaviours. Understanding of illness self-regulation and avenues for intervention might be enriched by consideration of automatic processes that influence the recognition and identification of illness, response to illness, and ongoing management. This article adopts an integrative approach to (1) outline the theoretical importance of implicit processes in patients' self-regulation of illness and methods to study them; (2) review research evidence for these processes, including interventions tested to modify them; and (3) outline avenues for future research. A substantial body of research on implicit processes (cognitive bias and interpretational bias) in illness maintenance in chronic illness has recently been extended to detection and interpretation of acute illness and new perspectives relating to the self-system. There is encouraging evidence that cognitive accessibility of coping and implicit attitudes may impact upon coping behaviours. Procedures that strategically automatise coping responses and create habits have considerable promise. We outline an agenda for future research in which health psychology accepts the challenge posed by the interplay of the reflective and associative systems in promoting effective self-regulation of illness.

Parent Attributions of Ambiguous Symptoms in Their Children: A Preliminary Measure Validation in Parents of Children with Chronic Pain

How parents attribute cause to their child’s physical symptoms is likely important in understanding how the parent responds to the child, as well as the child’s health outcomes, especially within the context of chronic illness. Here, we adapt the Symptom Interpretation Questionnaire for parent report (SIQ-PR) and provide preliminary validation in a sample of parents of children with chronic pain (N = 311). Confirmatory factor analysis revealed that the SIQ-PR structure is consistent with the original measure, with three distinct attribution types: psychological (emotional/affective), somatic (illness/disease), and environmental (situational/transient) causes. All three subscales demonstrated satisfactory to good internal consistency, and temporal stability. Parents typically endorsed more than one attribution for each symptom, indicating that parents of children with chronic pain have a multidimensional interpretation of physical symptoms in their children. Further, parent psychological and somatic attributions, but not environmental attributions, were significantly associated with (i) parent protective responses towards their child, and (ii) the child’s self-reported somatic and psychological symptoms, indicating convergent and divergent validity. The SIQ-PR may be a useful measure for future studies investigating intergenerational and interpersonal models of pediatric chronic pain, and more broadly, to examine parent attributions of children’s ambiguous symptoms within the context of childhood chronic illness.

Emotion dysregulation as a transdiagnostic mechanism of opioid misuse and suicidality among chronic pain patients

BACKGROUND

Chronic pain is a prevalent condition that causes functional impairment and emotional suffering. To allay pain-induced suffering, opioids are often prescribed for chronic pain management. Yet, chronic pain patients on opioid therapy are at heightened risk for opioid misuse-behaviors that can lead to addiction and overdose. Relatedly, chronic pain patients are at elevated risk for suicidal ideation and suicidal behaviors.

MAIN BODY

Opioid misuse and suicidality are maladaptive processes aimed at alleviating the negative emotional hyperreactivity, hedonic hyporeactivity, and emotion dysregulation experienced by chronic pain patients on opioid therapy. In this review, we explore the role of emotion dysregulation in chronic pain. We then describe why emotionally dysregulated chronic pain patients are vulnerable to opioid misuse and suicidality in response to these negative affective states.

CONCLUSION

Emotion dysregulation is an important and malleable treatment target with the potential to reduce or prevent opioid misuse and suicidality among opioid-treated chronic pain patients.

Cognitive Biases in Children and Adolescents With Chronic Pain: A Review of Findings and a Call for Developmental Research

Cognitive biases that emphasize bodily harm, injury, and illness could play a role in the maintenance of chronic pain by facilitating fear and avoidance. Whereas extensive research has established attention, interpretation, and memory biases in adults with chronic pain, far less is known about these same biases in children and adolescents with pain. Studying cognitive biases in attention, interpretation, and memory in relation to pain occurring in youth is important because youth is a time when pain can first become chronic, and when relationships between cognitive biases and pain outcomes emerge and stabilize. Thus, youth potentially offers a time window for the prevention of chronic pain problems. In this article, we summarize the growing corpus of data that have measured cognitive biases in relation to pediatric pain. We conclude that although biases in attention, interpretation, and memory characterize children and adolescents with varying pain experiences, questions regarding the direction, magnitude, nature, and role of these biases remain. We call for independent extension of cognitive bias research in children and adolescents, using well powered longitudinal studies with wide age ranges and psychometrically sound experimental measures to clarify these findings and any developmental trends in the links between cognitive biases and pain outcomes.

PERSPECTIVE

This article provides a rationale for the theoretical and practical importance of studying the role of cognitive biases in children and adolescents with chronic pain, which has to date, been relatively understudied. Existing findings are reviewed critically, and recommendations for future research are offered.