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Sharpe L, Rooney T, Todd J, Michalski SC, Van Ryckeghem D, Crombez G, Colagiuri B. Attentional Processes in Pain: The Importance of Context and Attentional Alignment. THE JOURNAL OF PAIN 2024:104600. [PMID: 38866122 DOI: 10.1016/j.jpain.2024.104600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 05/30/2024] [Accepted: 06/04/2024] [Indexed: 06/14/2024]
Abstract
The attentional bias literature has consistently failed to take context into account. We developed a novel paradigm in immersive virtual reality (VR) with pain stimuli where it would be adaptive or nonadaptive to attend to the stimuli. Participants had to indicate the location of the stimuli. Seventy participants were recruited. The VR-attention task assessed overall attentional bias (the tendency to prioritize pain compared with nonpain stimuli) and attentional alignment (the tendency to attend to pain more in adaptive than nonadaptive situations). Pain tolerance and threshold were measured using electrocutaneous stimulation and thermal pain. We conducted 2 (context: adaptive vs nonadaptive) × 2 (congruence: congruent vs incongruent) Analysis of Covariance, controlling for threat. Participants responded to pain probes more quickly in adaptive than nonadaptive contexts. There was an overall bias away from pain-related stimuli (avoidance) in reaction time to the target. There was also an interaction where avoidance was greater in nonadaptive contexts, indicative of attentional alignment. For gaze behavior, both attentional alignment and attentional bias were observed for latency to first fixation on the target, such that participants showed vigilance for pain particularly in the adaptive context. Attentional alignment was correlated with threshold and tolerance from electrocutaneous stimulation but not thermal pain. In conclusion, we found overall attentional biases indicating vigilance (latency to first fixation) and avoidance (response to target). We also found that participants evidenced a pattern of attention favoring adaptive over nonadaptive contexts (attentional alignment). It was attentional alignment, but not overall attentional bias, that predicted pain tolerance and threshold. PERSPECTIVE: The study explored attentional processes in pain through a novel paradigm designed in VR. The results found that positive attentional alignment, or the tendency to attend to pain more in adaptive contexts rather than nonadaptive contexts, predicted pain outcomes.
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Affiliation(s)
- Louise Sharpe
- School of Psychology A18, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia.
| | - Tessa Rooney
- School of Psychology A18, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Jemma Todd
- School of Psychology A18, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Stefan Carlo Michalski
- School of Psychology A18, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Dimitri Van Ryckeghem
- Department of Experimental-Clinical and Health Psychology, Ghent University, Ghent, Belgium; Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands; Department of Behavioural and Cognitive Sciences, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Geert Crombez
- Department of Experimental-Clinical and Health Psychology, Ghent University, Ghent, Belgium
| | - Ben Colagiuri
- School of Psychology A18, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
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Fonseca das Neves J, Kornacka M, Serra E, Rollin N, Kosinski T, Maréchal V, Jehel L, Rusinek S. The impact of rumination on fibromyalgia pain after physical activity: an experimental study. Sci Rep 2023; 13:20523. [PMID: 37993555 PMCID: PMC10665397 DOI: 10.1038/s41598-023-47414-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 11/03/2023] [Indexed: 11/24/2023] Open
Abstract
Some fibromyalgia (FM) patients engage in rumination (i.e. a chain of repetitive, passive and relatively uncontrollable thoughts focused on negative content) to cope with the pain and discomfort of daily activities. The partial model of rumination in chronic pain suggests that rumination processes may play a causal role in maintaining pain. Rumination might also be one of the key factors interfering with the reestablishment of adapted physical activity. The objective of this study was to test how rumination vs. distraction induction influence FM patients' pain intensity, discomfort linked to pain, and affect after physical activity. Forty-seven participants with a diagnosis of FM were randomly assigned to undergo distraction induction vs. rumination induction after performing a physical activity in ecological setting. Their pain intensity, pain-related discomfort, and affect were measured at the baseline, after physical activity, and after rumination versus distraction induction. A series of mixed-design ANOVAs showed that rumination induction after physical activity impairs patients' recovery in terms of pain intensity and discomfort, but not affect, as compared to the distraction condition. In conclusion, participants with fibromyalgia who engage in rumination following a physical activity recover less from their pain experience as compared to distraction induction. These results are consistent with the partial model of rumination in chronic pain and support the idea that rumination may play a causal role in the development and maintenance of pain.
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Affiliation(s)
| | - Monika Kornacka
- Emotion Cognition Lab, SWPS University, Technikow 9, 40-326, Katowice, Poland.
| | - Eric Serra
- Centre d'étude et de Traitement de la Douleur, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, France
- Univ. Lille, ULR 4072 - PSITEC - Psychologie: Interactions Temps Émotions Cognition, F-59000, Lille, France
- UFR Santé, Université de Picardie Jules Verne, Amiens, France
| | - Noémie Rollin
- Univ. Lille, ULR 4072 - PSITEC - Psychologie: Interactions Temps Émotions Cognition, F-59000, Lille, France
- Consultation de la Douleur, Centre Hospitalier de Soissons, Soissons, France
| | - Thierry Kosinski
- Univ. Lille, ULR 4072 - PSITEC - Psychologie: Interactions Temps Émotions Cognition, F-59000, Lille, France
| | - Virginie Maréchal
- Psychiatrie de Liaison, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, France
| | - Louis Jehel
- Psychiatrie de Liaison, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, France
- UFR Santé, Université de Picardie Jules Verne, Amiens, France
- Equipe MOODS-IPSOM, U1018, CESP/INSERM, 94807, Villejuif Cedex, France
| | - Stéphane Rusinek
- Univ. Lille, ULR 4072 - PSITEC - Psychologie: Interactions Temps Émotions Cognition, F-59000, Lille, France
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Motor action changes pain perception: a sensory attenuation paradigm in the context of pain. Pain 2021; 162:2060-2069. [PMID: 33863857 DOI: 10.1097/j.pain.0000000000002206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/13/2021] [Indexed: 01/05/2023]
Abstract
ABSTRACT A large body of evidence indicates how pain affects motor control, yet the way the motor system influences pain perception remains unclear. We present 2 experiments that investigated sensory attenuation of pain implementing a 2-alternative forced choice paradigm. Particularly, healthy participants received painful stimuli on a moving and nonmoving hand during the execution or the preparation of reaching motor actions. At the end of each trial, they indicated on which hand they perceived the stimulus stronger. The point of subjective equality was obtained to measure sensory attenuation. The intensity (experiment 1) and the threat value (experiment 2) of the pain stimuli were manipulated between-subjects to examine their impact on sensory attenuation. Results of experiment 1 (N = 68) revealed that executing a motor action attenuates pain processing in the moving hand. Sensory attenuation during motor preparation alone occurred with stronger stimulus intensities. Sensory attenuation was not affected by the intensity of the pain stimuli. Results of experiment 2 (N = 79) replicated the phenomenon of sensory attenuation of pain during motor action execution. However, sensory attenuation was not affected by the threat value of pain. Together these findings indicate that executing, but not preparing, a motor action affects pain processing in that body part. No significant associations were found between sensory attenuation indices and inhibitory control abilities or pain catastrophizing, vigilance and rumination. These results provide insight into the inhibitory effects of motor actions on pain processing, suggesting that pain perception is a dynamic experience susceptible to individuals' actions in the environment.
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Keogh E, Attridge N, Walsh J, Bartlett J, Francis R, Bultitude JH, Eccleston C. Attentional Biases Towards Body Expressions of Pain in Men and Women. THE JOURNAL OF PAIN 2021; 22:1696-1708. [PMID: 34174386 DOI: 10.1016/j.jpain.2021.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/18/2021] [Accepted: 06/04/2021] [Indexed: 12/30/2022]
Abstract
This study investigated whether there are gender differences in attention to bodily expressions of pain and core emotions. Three experiments are reported using the attentional dot probe task. Images of men and women displaying bodily expressions, including pain, were presented. The task was used to determine whether participants' attention was drawn towards or away from target expressions. Inconsistent evidence was found for an attentional bias towards body expressions, including pain. While biases were affected by gender, patterns varied across the Experiments. Experiment 1, which had a presentation duration of 500 ms, found a relative bias towards the location of male body expressions compared to female expressions. Experiments 2 and 3 varied stimulus exposure times by including both shorter and longer duration conditions (e.g., 100 vs. 500 vs. 1250 ms). In these experiments, a bias towards pain was confirmed. Gender differences were also found, especially in the longer presentation conditions. Expressive body postures captured the attention of women for longer compared to men. These results are discussed in light of their implications for why there are gender differences in attention to pain, and what impact this has on pain behaviour. PERSPECTIVE: We show that men and women might differ in how they direct their attention towards bodily expressions, including pain. These results have relevance to understanding how carers might attend to the pain of others, as well as highlighting the wider role that social-contextual factors have in pain.
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Affiliation(s)
- Edmund Keogh
- Department of Psychology, University of Bath, UK; Bath Centre for Pain Research, University of Bath, UK.
| | | | - Joseph Walsh
- School of Society, Enterprise & Environment, Bath Spa University, UK
| | | | | | - Janet H Bultitude
- Department of Psychology, University of Bath, UK; Bath Centre for Pain Research, University of Bath, UK
| | - Christopher Eccleston
- Bath Centre for Pain Research, University of Bath, UK; Department of Clinical and Health Psychology, Ghent University, Belgium
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No evidence that attentional bias towards pain-related words is associated with verbally induced nocebo hyperalgesia: a dot-probe study. Pain Rep 2021; 6:e921. [PMID: 33981937 PMCID: PMC8108596 DOI: 10.1097/pr9.0000000000000921] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 12/02/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. This study examined attention as a mechanism of nocebo hyperalgesia. No association was observed between attentional bias towards pain-related words and nocebo hyperalgesia. Introduction: Placebo and nocebo effects in pain are well documented. One leading explanation is that instructions indicating that pain will either increase or decrease after receipt of a treatment give rise to expectations for increased or decreased pain. However, the psychological mechanisms through which expectations affect pain perception are not well understood. One possibility is that the expectation of increased pain leads to anticipatory anxiety, which in turn increases attention towards painful sensations. Objectives: The aim of this study was to test the hypothesis that attention mediates nocebo hyperalgesia. This was done by measuring attentional bias towards pain using a dot-probe task both before and after a nocebo manipulation. Methods: Ninety-six healthy volunteers were randomized to receive one of the following: (1) an inert nasal spray with placebo instructions, (2) an inert nasal spray with nocebo instructions, or (3) no treatment. Participants completed measures of expectations, anxiety, and attention bias (dot-probe paradigm) both before and after randomization. Results: Results showed that the nocebo instructions induced expectations for increased pain and resulted in nocebo hyperalgesia. Conversely, the placebo instruction failed to induce expectations for decreases in pain and did not demonstrate any placebo analgesia. Furthermore, despite the significant expectancies for pain and subsequent nocebo hyperalgesia, there were no differences between the nocebo group and either the placebo or no-treatment group for anxiety or attentional bias. Conclusion: The results are consistent with the expectancy model of placebo and nocebo effects. That is, changes in expectations seemed to be necessary to induce a placebo or nocebo effect. However, there was no evidence that anxiety or attention bias towards pain-related stimuli was necessary to achieve nocebo hyperalgesia.
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Rubio A, Oyanedel JC, Bilbao M, Mendiburo-Seguel A, López V, Páez D. Suicidal Ideation Mediates the Relationship Between Affect and Suicide Attempt in Adolescents. Front Psychol 2020; 11:524848. [PMID: 33414735 PMCID: PMC7782311 DOI: 10.3389/fpsyg.2020.524848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 11/20/2020] [Indexed: 11/21/2022] Open
Abstract
Suicide, as one of the leading causes of death for the adolescent population, both in Chile and globally, remains a complex and elusive phenomenon. This research studies the association between positive and negative affect in relation with suicidal ideation and suicidal attempt, given that affectivity is a fundamental basis on which people make evaluations on their satisfaction with life. First, it examines the reliability, structure, and validity of Watson's positive and negative affect scale (PANAS) scale in a representative random sample of Chilean high school students (N = 4,568). The scale evidences strong reliability coefficients and a confirmatory factor analysis, excluding one positive (excited) and one negative (nervous) item. The scale shows a satisfactory goodness of fit. Secondly, it investigates the association of PANAS positive and negative affect scores with suicidal ideation as well as reported attempt in adolescents, controlling for the potential effect of age and sex (N = 420 high school students). Low positive and high negative affect, but not sex and age, show a significant association with suicidal ideation. Suicidal ideation totally mediates the association of affect with suicide attempt, as expected. Results are discussed regarding prevention and it considers how positive and negative affect can be relevant as indicators for prevention and treatment using widely available technology.
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Affiliation(s)
- Andrés Rubio
- Facultad de Economía y Negocios, Universidad Andres Bello, Santiago, Chile
- Facultad de Psicología, Universidad Diego Portales, Santiago, Chile
| | - Juan Carlos Oyanedel
- Facultad de Educación y Ciencias Sociales, Universidad Andres Bello, Santiago, Chile
| | - Marian Bilbao
- Facultad de Psicología, Universidad Alberto Hurtado, Santiago, Chile
| | | | - Verónica López
- Facultad de Psicología, Pontificia Universidad Católica de Valparaíso, Viña del Mar, Chile
| | - Dario Páez
- Facultad de Educación y Ciencias Sociales, Universidad Andres Bello, Santiago, Chile
- Faculty of Psychology, University of the Basque Country, San Sebastian, Spain
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Rogers AH, Bakhshaie J, Ditre JW, Manning K, Mayorga NA, Viana AG, Zvolensky MJ. Worry and rumination: Explanatory roles in the relation between pain and anxiety and depressive symptoms among college students with pain. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2019; 67:275-282. [PMID: 29979938 DOI: 10.1080/07448481.2018.1481071] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 04/09/2018] [Accepted: 05/18/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Pain affects a significant proportion of college students in the United States and has been linked to anxiety and depressive symptoms. Rumination and worry, two transdiagnostic factors linked to comorbidity, may explain the relationship between pain and mental health symptoms. Current Study: The current study examined worry and rumination as explanatory factors in the relationship between pain and anxiety and depressive symptoms in a sample of college students with pain (n = 1,577; 79.9% female). RESULTS Results indicated that both rumination and worry explained the relationship between pain and depressive and social anxiety symptoms, while rumination alone explained the relationship between pain and anxious arousal symptoms. CONCLUSION The current study provides novel empirical evidence that worry and rumination each help explain the relationship between pain and anxiety and depressive symptoms among college students with current pain, and college students in pain may benefit from targeted psychosocial strategies aimed at decreasing worry and ruminative responses.
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Affiliation(s)
- Andrew H Rogers
- a Department of Psychology , University of Houston , Houston , Texas , USA
| | - Jafar Bakhshaie
- a Department of Psychology , University of Houston , Houston , Texas , USA
| | - Joseph W Ditre
- b Department of Psychology , Syracuse University , Syracuse , New York , USA
| | - Kara Manning
- a Department of Psychology , University of Houston , Houston , Texas , USA
| | - Nubia A Mayorga
- a Department of Psychology , University of Houston , Houston , Texas , USA
| | - Andres G Viana
- a Department of Psychology , University of Houston , Houston , Texas , USA
| | - Michael J Zvolensky
- a Department of Psychology , University of Houston , Houston , Texas , USA
- c Department of Behavioral Sciences , University of Texas MD Anderson Cancer Center , Houston , Texas , USA
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Shires A, Sharpe L, Newton John TRO. The relative efficacy of mindfulness versus distraction: The moderating role of attentional bias. Eur J Pain 2018; 23:727-738. [DOI: 10.1002/ejp.1340] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 11/06/2018] [Accepted: 11/07/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Alice Shires
- School of Psychology University of Sydney Sydney New South Wales Australia
- Clinical Psychology Department, Graduate School of HealthUniversity of Technology Sydney New South Wales Australia
| | - Louise Sharpe
- School of Psychology University of Sydney Sydney New South Wales Australia
| | - Toby R. O. Newton John
- Clinical Psychology Department, Graduate School of HealthUniversity of Technology Sydney New South Wales Australia
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Todd J, van Ryckeghem DM, Sharpe L, Crombez G. Attentional bias to pain-related information: a meta-analysis of dot-probe studies. Health Psychol Rev 2018; 12:419-436. [DOI: 10.1080/17437199.2018.1521729] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Jemma Todd
- School of Psychology, University of Sydney, Sydney, Australia
| | - Dimitri M.L. van Ryckeghem
- Department of Experimental Psychology, Ghent University, Ghent, Belgium
- Research Unit INSIDE, Institute for Health and Behaviour; Faculty of Language and Literature, Humanities, Arts and Education, Luxembourg University, Luxembourg City, Luxembourg
| | - Louise Sharpe
- School of Psychology, University of Sydney, Sydney, Australia
| | - Geert Crombez
- Department of Experimental Psychology, Ghent University, Ghent, Belgium
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10
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Keogh E, Cheng F, Wang S. Exploring attentional biases towards facial expressions of pain in men and women. Eur J Pain 2018; 22:1617-1627. [DOI: 10.1002/ejp.1244] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2018] [Indexed: 12/30/2022]
Affiliation(s)
- E. Keogh
- Department of Psychology; University of Bath; UK
- Centre for Pain Research; University of Bath; UK
| | - F. Cheng
- Department of Psychology; University of Bath; UK
| | - S. Wang
- Department of Psychology; University of Bath; UK
- Centre for Pain Research; University of Bath; UK
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11
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Alexeeva I, Martin M. Evidence for mood-dependent attentional processing in asthma: attentional bias towards health-threat in depressive mood and attentional avoidance in neutral mood. J Behav Med 2018; 41:550-567. [PMID: 29626313 PMCID: PMC6061078 DOI: 10.1007/s10865-018-9919-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 03/16/2018] [Indexed: 11/26/2022]
Abstract
Attentional biases have been observed in populations with psychological disorders, but have been under-investigated in populations with physical illnesses. This study investigated potential attentional biases in asthma as a function of mood. Asthma (N = 45), and healthy (N = 39) participants were randomly allocated to a depressed or a neutral mood state induction. They completed a visual probe task that measured participants’ reaction times to health-threat and neutral pictures and words. Compared to the healthy controls, the asthma group showed attentional bias towards health-threat pictures in depressed mood, and avoidance of health-threat pictures in neutral mood. Attentional biases were found in a group with a physical illness as a function of induced mood. It is suggested that attentional processes in people with physical illness may be important in relation to symptom perception and illness management.
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Affiliation(s)
- Iana Alexeeva
- Medical Sciences Division, Department of Experimental Psychology, University of Oxford, Anna Watts Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Maryanne Martin
- Medical Sciences Division, Department of Experimental Psychology, University of Oxford, Anna Watts Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
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Paulus DJ, Ditre JW, Viana AG, Bakhshaie J, Garza M, Valdivieso J, Ochoa-Perez M, Lemaire C, Zvolensky MJ. Pain and Alcohol Use among Latinos in Primary Care: Examining Rumination as an Explanatory Factor. Subst Use Misuse 2018; 53:686-693. [PMID: 29035124 DOI: 10.1080/10826084.2017.1361998] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Alcohol is a widely abused substance among Latinos. Yet, little is known regarding factors underlying hazardous drinking in this population. Growing work has linked pain to hazardous drinking, although highly limited work has focused on Latinos. OBJECTIVES The aim of the current study was to test rumination as an underlying mechanism explaining relations between pain severity and alcohol use among Latinos. METHODS Data from 252 low-income Latino adults (Mage = 38.7 years, SD = 10.8; 86.1% female) attending a community-based primary health care clinic were available. Participants completed measures of pain, rumination, and alcohol use. Structural equation modeling was used to evaluate the indirect effect of pain severity via rumination on alcohol use. RESULTS The model displayed good fit to the data. There was a statistically significant indirect effect of pain severity via rumination on alcohol use. Conclusions/Importance: The current findings suggest that rumination may underlie associations of pain and alcohol use among Latinos. Future work in primary care medical settings may benefit from targeting ruminative thinking among Latinos who are experiencing pain to address hazardous drinking.
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Affiliation(s)
- Daniel J Paulus
- a Department of Psychology , University of Houston , Houston , Texas , USA
| | - Joseph W Ditre
- b Department of Psychology , Syracuse University , Syracuse , New York , USA
| | - Andres G Viana
- a Department of Psychology , University of Houston , Houston , Texas , USA.,c Texas Institute for Measurement, Evaluation, and Statistics , University of Houston , Houston , Texas , USA
| | - Jafar Bakhshaie
- a Department of Psychology , University of Houston , Houston , Texas , USA
| | - Monica Garza
- d Legacy Community Health Services , Houston , Texas , USA
| | | | | | - Chad Lemaire
- d Legacy Community Health Services , Houston , Texas , USA
| | - Michael J Zvolensky
- a Department of Psychology , University of Houston , Houston , Texas , USA.,e Department of Behavioral Science , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
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