Repeated exposure to others' pain reduces vicarious pain intensity estimation

Looking through Providers' Eyes: Pain in the Neonatal Intensive Care Unit

OBJECTIVE

 Evaluate the pain of critically ill newborns is a challenge because of the devices for cardiorespiratory support. This study aim to verify the adults' gaze when assessing the critically ill neonates' pain at bedside.

STUDY DESIGN

 Cross-sectional study in which pediatricians, nursing technicians, and parents evaluated critically ill neonates' pain at bedside, for 20 seconds with eye-tracking glasses. At the end, they answered whether the neonate was in pain or not. Visual tracking outcomes: number and time of visual fixations in four areas of interest (AOI) (face, trunk, and upper [UL] and lower [LL] limbs) were compared between groups and according to pain perception (present/absent).

RESULTS

 A total of 62 adults (21 pediatricians, 23 nursing technicians, 18 parents) evaluated 27 neonates (gestational age: 31.8 ± 4.4 weeks; birth weight: 1,645 ± 1,234 g). More adults fixed their gaze on the face (96.8%) and trunk (96.8%), followed by UL (74.2%) and LL (66.1%). Parents performed a greater number of fixations on the trunk than nursing technicians (11.0 vs. 5.5 vs. 6.0; p = 0.023). Controlled for visual tracking variables, each second of eye fixation in AOI (1.21; 95% confidence interval [CI]: 1.03-1.42; p = 0.018) and UL (1.07; 95% CI: 1.03-1.10; p < 0.001) increased the chance of perceiving the presence of pain.

CONCLUSION

 Adults, when assessing at bedside critically ill newborns' pain, fixed their eyes mainly on the face and trunk. The time spent looking at the UL was associated with the perception of pain presence.

KEY POINTS

· Pain assessment in critically ill newborns is a challenge.. · To assess critically ill neonates' pain, adults mainly look at the face and trunk.. · Looking at the upper limbs also helps in assessing critically ill neonates' pain..

The Relationship Between the Ability to Infer Another's Pain and the Expectations Regarding the Appearance of Pain Facial Expressions: Investigation of the Role of Visual Perception

Although pain is a commonly experienced and observed affective state, it is frequently misinterpreted, which leads to inadequate caregiving. Studies show the ability at estimating pain in others (estimation bias) and detecting its subtle variations (sensitivity) could emerge from independent mechanisms. While estimation bias is modulated by variables such as empathy level, pain catastrophizing tendency, and overexposure to pain, sensitivity remains unimpacted. The present study verifies if these 2 types of inaccuracies are partly explained by perceptual factors. Using reverse correlation, we measured their association with participants' mental representation of pain, or more simply put, with their expectations of what the face of a person in pain should look like. Experiment 1 shows that both parameters are associated with variations in expectations of this expression. More specifically, the estimation bias is linked with expectations characterized by salient changes in the middle face region, whereas sensitivity is associated with salient changes in the eyebrow region. Experiment 2 reveals that bias and sensitivity yield differences in emotional representations. Expectations of individuals with a lower underestimation tendency are qualitatively rated as expressing more pain and sadness, and those of individuals with a higher level of sensitivity as expressing more pain, anger, and disgust. Together, these results provide evidence for a perceptual contribution in pain inferencing that is independent of other psychosocial variables and its link to observers' expectations. PERSPECTIVE: This article reinforces the contribution of perceptual mechanisms in pain assessment. Moreover, strategies aimed to improve the reliability of individuals' expectations regarding the appearance of facial expressions of pain could potentially be developed, and contribute to decrease inaccuracies found in pain assessment and the confusion between pain and other affective states.

Feasibility of a brief mindfulness-based program for burnout in pain healthcare professionals

Introduction

Stress inherent to health care, which is characterized by work overload and shortage of specialized staff, is associated with decreased quality of life and suboptimal patient care. Mindfulness-based programs have proved to be effective in reducing stress in healthcare providers. This study aims to assess the feasibility of an 8-week mindfulness program to reduce the burnout levels of the staff of a pain clinic in a tertiary public hospital.

Materials and methods

A longitudinal study with a within subject pre/post-intervention design, consisting of daily face-to-face 10-min sessions and the creation of a virtual group using a social media platform. Variables measured: burnout, mindfulness, empathy, self-compassion, and demographic characteristics.

Results

Program feasibility (i.e., reach, adherence, acceptability, and preliminary effectiveness) was evaluated in 10 participants (6 physicians, 2 nurse practitioners, 1 nursing assistant, and 1 administrative). The results revealed a high reach (i.e., participation rate of 90%), excellent adherence to the program (daily practice 95% of times), and very good acceptability of the group format and satisfaction with most treatment components. Regarding potential effectiveness, we report the results of the Wilcoxon signed-rank tests and its associated effect size (r). We observed improvements in mindfulness and all its subscales (−2.077 ≤ Z ≤ −2.703, 0.69 ≤ r ≤ 0.90, all p &lt; 0.05) except for non-reactivity and all subcomponents of self-compassion (−2.501 ≤ Z ≤ −2.611, 0.83 ≤ r ≤ 0.87, all p &lt; 0.05) but not on its global self-compassion score. Empathy and burnout did not change. In an exploratory manner, however, we found significant reductions in the burnout component of emotional exhaustion, but only in physicians (Z = −2.201, p = 0.028, r = 0.73).

Discussion

We believe that the 8-week mindfulness-based program described in the present investigation might be a feasible and potentially effective method that can be easily implemented to reduce burnout and promote mindfulness in specialized pain clinics.

Insensitivity to Suffering: Psychopathic Traits and Perception of Others' Pain

Despite growing evidence that psychopathy entails reduced emotional processing, the relationship between psychopathic traits and third-person pain perception is poorly understood. This study directly examined perception of others' pain in a sample of male and female students (N = 105) who completed the Self-Report Psychopathy scale (SRP-III) and the Toronto Empathy Questionnaire (TEQ). Participants watched a video of 60 one-second clips of other people experiencing pain. Following each clip, participants rated the perceived level of pain intensity and pain unpleasantness. Psychopathic traits were unrelated to response bias, suggesting that individuals high in psychopathic traits were no more or less likely to impute pain to others. However, higher levels of psychopathic traits, particularly callous affect and antisocial behavior, were associated with a decreased ability to discriminate others' pain. Sensitivity and response bias were unrelated to TEQ scores. These findings provide novel insights into the influence of psychopathic traits on emotional processing.

Pain severity scores for common equine disorders as provided by horse owners and equine veterinarians

BACKGROUND

Understanding factors influencing assessment of pain in horses will facilitate communication between veterinarians and horse owners.

OBJECTIVES

To compare estimates of pain experienced by horses as provided by veterinarians and horse owners and to determine factors associated with individuals who perceive horses to be experiencing extreme pain or minimal pain.

STUDY DESIGN

Cross-sectional study.

METHODS

Internet-based questionnaires for horse owners and veterinarians included items related to recognition of pain in horses, estimated degree of pain experienced by horses, and demographic information. Variables associated with perception of a high or low degree of pain were investigated using logistic regression analyses.

RESULTS

Final data sets included responses from 553 horse owners and 263 veterinarians. Pain scores varied widely and differences in median scores from horse owners and veterinarians were small. Horse owners providing high pain ratings were more likely to have < 10 horses (odds ratio [OR] = 2.0, 95% CI = 1.1 - 3.5) and to not have a college degree (OR = 1.5, 95% CI = 1.0-2.2). Those providing low pain ratings were less likely to own < 10 horses (OR = 0.6, 95% Confidence Interval [CI] = 0.4 - 0.9). Veterinarians providing high pain ratings were more likely to be employed in a mixed animal practice (OR = 2.8, 95% CI = 1.3 - 5.9) and to lack board-certification in a veterinary specialty (OR = 2.1, 95% CI = 1.1 - 4.2). Veterinarians providing low pain ratings were more likely to be male (OR = 2.4, 95% CI = 1.3 - 4.2).

MAIN LIMITATIONS

The respondent population may be biased because of the method of questionnaire distribution and associated sampling bias. Respondents were primarily from the United States.

CONCLUSIONS

Assessments of the degree of pain horses are experiencing vary widely among horse owners and equine veterinarians.

Gender Biases in Estimation of Others' Pain

Caregiving and other interpersonal interactions often require accurate perception of others' pain from nonverbal cues, but perceivers may be subject to systematic biases based on gender, race, and other contextual factors. Such biases could contribute to systematic under-recognition and undertreatment of pain. In 2 experiments, we studied the impact of perceived patient sex on lay perceivers' pain estimates and treatment recommendations. In Experiment 1 (N = 50), perceivers viewed facial video clips of female and male patients in chronic shoulder pain and estimated patients' pain intensity. Multi-level linear modeling revealed that perceivers under-estimated female patients' pain compared with male patients, after controlling for patients' self-reported pain and pain facial expressiveness. Experiment 2 (N = 200) replicated these findings, and additionally found that 1) perceivers' pain-related gender stereotypes, specifically beliefs about typical women's vs. men's willingness to express pain, predicted pain estimation biases; and 2) perceivers judged female patients as relatively more likely to benefit from psychotherapy, whereas male patients were judged to benefit more from pain medicine. In both experiments, the gender bias effect size was on average 2.45 points on a 0-100 pain scale. Gender biases in pain estimation may be an obstacle to effective pain care, and experimental approaches to characterizing biases, such as the one we tested here, could inform the development of interventions to reduce such biases. Perspective: This study identifies a bias towards underestimation of pain in female patients, which is related to gender stereotypes. The findings suggest caregivers' or even clinicians' pain stereotypes are a potential target for intervention.

Towards Machine Recognition of Facial Expressions of Pain in Horses

Automated recognition of human facial expressions of pain and emotions is to a certain degree a solved problem, using approaches based on computer vision and machine learning. However, the application of such methods to horses has proven difficult. Major barriers are the lack of sufficiently large, annotated databases for horses and difficulties in obtaining correct classifications of pain because horses are non-verbal. This review describes our work to overcome these barriers, using two different approaches. One involves the use of a manual, but relatively objective, classification system for facial activity (Facial Action Coding System), where data are analyzed for pain expressions after coding using machine learning principles. We have devised tools that can aid manual labeling by identifying the faces and facial keypoints of horses. This approach provides promising results in the automated recognition of facial action units from images. The second approach, recurrent neural network end-to-end learning, requires less extraction of features and representations from the video but instead depends on large volumes of video data with ground truth. Our preliminary results suggest clearly that dynamics are important for pain recognition and show that combinations of recurrent neural networks can classify experimental pain in a small number of horses better than human raters.

Interrater Variability in Pain Assessment of Long-term Care Residents with Dementia

PURPOSE

People with dementia are at great risk of their pain being undetected. In long-term care facilities, certified nursing assistants are on the front-line to detect whether a resident with dementia is experiencing pain, but research on certified nursing assistants' abilities to accurately assess pain are scarce. This study aims to examine certified nursing assistants' pain assessment skills using a simulated standardized video context.

DESIGN

A cross-sectional study was conducted.

METHODS

Fifty certified nursing assistants and 40 individuals with no professional experience in the field of care (controls) watched the same video of an older adult woman with dementia experiencing pain. Afterwards, they completed visual analog scales (pain intensity, affective distress), an observational pain assessment scale (Algoplus), and a set of questionnaires.

RESULTS

In both groups, pain intensity assessment and empathic reaction scores showed important interrater variability. Moreover, certified nursing assistants and controls did not differ in detecting the presence of pain or assessing its intensity. But certified nursing assistants displayed lower empathic reactions and dispositions. Certified nursing assistants pain assessment scores decreased with experience and expertise.

CONCLUSIONS

The practice of pain assessment is challenging for certified nursing assistants in long-term care facilities. Their professional status does not prevent inter-personal inconsistency and tends to lower their empathic dispositions. Personal determinants may interfere with their assessment behaviors and must be considered to enhance pain management for residents with dementia.

I Can But I Shall Not Always Be Empathic

Empathy, a core process for social interactions, is the capacity to understand and share others' mental states and emotions. Each individual is thought to have a maximum level of empathy (empathic ability) and a spontaneous tendency to express it (empathic propensity), which can be affected by multiple factors. Two within-subject studies were conducted to assess the malleability of empathy by modulating contextual factors and measuring their interaction with psychological characteristics. In Study 1, 59 healthy adults evaluated their empathy for people showing facial expressions of pain following different instructions: Passive Observation and Instruction to Actively Empathize. In Study 2, 56 healthy adults performed a similar task under two conditions: Passive Observation and Observation under a Cognitive Load. The results revealed that empathy was significantly increased in the actively empathizing condition (Study 1) and under a cognitive load, but more importantly for men (Study 2). The level of change between the two conditions was associated with self-reported empathy, autistic, alexithymia and psychopathic traits (Study 1), as well as with working memory capacities and the level of empathy reported in the passive observation condition (Study 2). These findings suggest that an instruction to actively empathize and, surprisingly, a cognitive load can both increase empathy, but not for the same individuals. An instruction to actively empathize seems to increase empathy for individuals with good empathic dispositions, while a cognitive load enhances empathy in people for which empathic propensity is sub-optimal.

Neural correlates of prosocial behavior towards persons in pain in healthcare providers

Pain perceived in others can be a stressful signal that elicits personal distress and discomfort that can interfere with prosocial behaviors. Healthcare providers (HCPs) have to be able to regulate these self-oriented feelings to offer optimal help to patients in pain. However, previous studies have documented a tendency in HCPs to underestimate the pain of patients that could interfere with optimal help to these patients. The aim of this study was to compare HCP and control (CTL) participants' prosocial behavior towards persons in pain and their associated brain responses. HCPs and CTL participants took part in a newly developed prosocial task during which they were asked to choose how much time they wanted to offer to help patients in pain. It was shown that compared to CTL participants, HCPs offered more help to persons in pain and reported less trait personal distress when facing suffering in others. Additional evidence was provided by the fMRI results, which indicated that compared to CTL participants, HCP participants showed different pattern of activity in the dorsolateral prefrontal cortex, bilateral precuneus and the posterior cingulate cortex during the prosocial task, suggesting that the underlying mechanisms of the difference in prosocial behaviors could vary according to the degree to which processes such as mentalizing and cognitive control are solicited.