Assessing the content specificity of interpretation biases in community adolescents with persistent and interfering 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.

Threat biases associate with anxiety and depression in physically-abused young people with a history of child labour

BACKGROUND AND OBJECTIVES

Young people who have experienced early-life maltreatment preferentially attend to threat and draw more threatening interpretations. In turn, these threat biases may explain elevated risk for lifelong anxiety and/or depression. We investigated whether adolescent labourers with a history of physical abuse showed threat biases relative to non-abused labourers, and whether these threat biases associated with anxiety and depression.

METHODS

100 young people (aged 13-18 years, 64% female) from Nepal rescued from illegal child work were assessed for childhood maltreatment and anxiety and/or depression disorders. Participants completed an emotional visual search task (to measure attention engagement of positive versus negative faces) and an ambiguous scenarios questionnaire (to measure the endorsement of negative versus benign interpretations).

RESULTS

Seventy young people reported a history of physical (and emotional) abuse. They were more likely to meet symptom thresholds for depression, and marginally, for anxiety disorders than non-physically abused participants. Abused and non-abused participants did not differ on attention engagement/disengagement of threat or on interpretational style. Abused participants with anxiety were slower to disengage from negative faces to engage with a positive face than non-anxious abused participants. Abused participants with depression endorsed more negative interpretations of ambiguous situations than those without depression.

LIMITATIONS

The cross-sectional design limits our ability to infer whether threat biases reflect risk markers of psychopathology.

CONCLUSIONS

If threat biases are shown to confer risk for anxiety and depression in future studies, they could be targeted in mental health prevention programs for these vulnerable young people.

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.

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.

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.

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.