The role of experiential avoidance in acute pain tolerance: a laboratory test

Change in negative mental filter is associated with depression reduction in metacognitive training for depression in older adults (MCT-Silver)

Identifying components of modularized psychological interventions that contribute to symptom reduction is essential to improving depression treatment. In a secondary analysis of a randomized controlled trial (RCT), session-specific effects of Metacognitive Training-Silver, a group intervention for older adults with depression, were investigated. Thirty-eight older adults with major depressive disorder or dysthymia participated in up to eight sessions of MCT-Silver. A clinical assessment of depressive symptoms (Hamilton Depression Rating Scale) as well as additional interviews and questionnaires administered as part of the RCT were completed at pre- and post-intervention. Depressive symptoms, negative (meta)cognitive beliefs, emotion regulation strategies and attitudes toward aging were assessed pre- and post-session. The rate of change in each variable per module, elevation following the module in which the variable was addressed, and the rate of change post module were examined via linear mixed models. Clinician-rated depressive symptoms were significantly reduced from pre- to post-intervention (Cohens d = 1.31). Self-reported depression and negative mental filter measured within sessions improved significantly over treatment, whereas black-and-white thinking improved after module #3 (Should Statements, All or Nothing Thinking and Acceptance). Module-specific within-session effects were found for overgeneralization (module #1: Mental Filter) and rumination (module #6: Rumination and Social Withdrawal). Improvement in mental filter in module #1 was significantly associated with depression reduction. This study provides initial evidence that MCT-Silver partially meets its aims of reducing depression and specific cognitive variables within and across sessions. Improvement of the instrument used to measure change may improve detection of module-specific effects.Trial registration: NCT03691402.

Higher emotion regulation flexibility predicts more stable negative emotions and faster affective recovery in early psychosis: an experience sampling study

BACKGROUND

While evidence shows that people with early psychosis are flexible in using different emotion regulation (ER) strategies to manage the varying contextual demands, no studies have examined the effectiveness of such regulatory flexibility in this population. We addressed this issue by investigating whether and how ER flexibility relate to different dynamic aspects (variability, instability, inertia, and recovery) of negative affect (NA) in a combined early psychosis sample, consisting of both individuals at high clinical risk for psychosis and those diagnosed with first-episode psychosis.

METHODS

Participants were 148 individuals from the INTERACT project, a multi-center randomized controlled trial on the efficacy of acceptance and commitment therapy in early psychosis. We utilized data from the baseline assessment, during which all participants completed six days of experience sampling assessment of momentary NA, as well as end-of-day assessments of ER strategy use.

RESULTS

Multilevel models of within-person associations showed that greater ER flexibility was associated with more stable NA, and quicker recovery of NA from stressors during the day. Linear regression analyses of between-person associations showed that people who had more variable and unstable NA reported greater ER flexibility generally. No evidence was found for associations with NA inertia.

CONCLUSIONS

The current study identified unique within-person and between-person links between ER flexibility and dynamics of NA in early psychosis. These findings further provide evidence for ER flexibility in early psychosis, emphasizing the adaptive nature of regulatory flexibility in relation to reduced instability in NA and faster recovery from NA in everyday life.

Experiential Avoidance as a Factor in Generalized Psychological Vulnerability: In the Relationship Between Chronic Pain and Pain Anxiety With Pain Disability

BACKGROUND

Pain is a major socio-psychological problem worldwide. Chronic pain has a negative effect on areas of psychological functioning such as depression, anxiety, and perceived stress.

AIM

The present study investigated the mediating role of experiential avoidance in the relationship between chronic pain and pain anxiety with pain disability.

METHODS

Participants were treatment-seeking patients (N = 361) at an outpatient pain clinic in Shiraz (Fars, Iran). The Multidimensional Pain Inventory (MPI), Pain Anxiety Symptom Scale (PASS-20), Pain Disability Questionnaire (PDQ), and Acceptance and Action Questionnaire-II (AAQ-II) were used to measure multidimensional pain, anxiety, pain disability, experiential avoidance, and pain severity.

RESULTS

The results of the correlation revealed that a significant relationship exists between multidimensional pain and pain anxiety, pain disability, and experiential avoidance. Experiential avoidance mediated the associations from multidimensional pain and pain disability significantly. Also, experiential avoidance moderated associations between pain anxiety and pain disability significantly. In general, Structural Equation Modeling (SEM) showed that experiential avoidance mediated the relationship between multidimensional pain and pain anxiety with pain disability.

CONCLUSION

In general, the results revealed that experiential avoidance can mediate the relationship among pain, pain anxiety, and pain disability as a maladaptive regulation strategy. The results obtained from this study seem to introduce experiential avoidance as a vulnerability factor effectively.

Experiential Avoidance, Pain, and Suicide Risk in a National Sample of Gulf War Veterans

OBJECTIVE

Pain confers risk for suicidal thoughts and behaviors. Experiential avoidance (EA), which is relevant to both pain and suicide risk, has not been studied as a potential mechanism for this relationship. The present study tested the hypothesis that pain indirectly impacts suicide risk through EA in a national sample of Gulf War veterans.

METHODS

Participants included a stratified random sample of United States veterans (N = 1,012, 78% male) who had served in the Gulf War region between August 1990 and July 1991. Validated scales were used to quantify levels of pain, EA, and suicide risk.

RESULTS

Regression analyses indicated independent associations between pain, EA, and suicide risk; moreover, the association between pain and suicide risk was no longer significant once EA was included in model. Bootstrapping analyses confirmed that EA partially accounted for the cross-sectional association between pain and suicide risk, independent of common co-occurring problems, such as depression, PTSD, and alcohol use disorder symptoms.

CONCLUSIONS

EA could be a key modifiable risk factor to target in people experiencing pain.

The impact of rumination on fibromyalgia pain after physical activity: an experimental study

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.

Intraindividual change in pain tolerance and negative affect over 20 years: findings from the MIDUS study

Pain tolerance, defined as the ability to withstand physical pain states, is a clinically important psychobiological process associated with several deleterious outcomes, including increased pain experience, mental health problems, physical health problems, and substance use. A significant body of experimental work indicates that negative affect is associated with pain tolerance, such that increased negative affect is associated with decreased pain tolerance. Although research has documented the associations between pain tolerance and negative affect, little work has examined these associations over time, and how change in pain tolerance is related to changes in negative affect. Therefore, the current study examined the relationship between intraindividual change in self-reported pain tolerance and intraindividual change in negative affect over 20 years in a large, longitudinal, observation-based national sample of adults (n = 4,665, Mage = 46.78, SD =12.50, 53.8% female). Results from parallel process latent growth curve models indicated that slope of pain tolerance and negative affect were associated with each other over time (r = .272, 95% CI [.08, .46] p = .006). Cohen's d effect size estimates provide initial, correlational evidence that changes in pain tolerance may precede changes in negative affect. Given the relevance of pain tolerance to deleterious health outcomes, better understanding how individual difference factors, including negative affect, influence pain tolerance over time, are clinically important to reduce disease-related burden.

Acceptance: A Research Overview and Application of This Core ACT Process in ABA

Acceptance describes mediating behaviors in which an individual reduces escape and avoidance behaviors in response to unwanted private events while also encouraging increased appetitive control. Given the recent resurgence of interest in acceptance and commitment therapy/training (ACT) in applied behavior analysis (ABA), a review of this core treatment process is warranted. Acceptance has strong empirical support within the psychological and contextual behavioral science literatures, with treatment outcome studies, self-report measures research, and behavioral laboratory tasks all supporting the process. A review of select publications in behavior-analytic journals found that acceptance also has preliminary evidence of effectiveness across a variety of populations and problem behaviors in ABA. An application of acceptance in an ABA context is discussed, and recommendations for a more functional approach to acceptance and other ACT processes are offered. Acceptance interventions fall within the scope of practice of ABA in several contexts and are of relevance to mainstream ABA practitioners.

Measuring Public Speaking Anxiety: Self-report, behavioral, and physiological

Self-reports are typically used to assess public speaking anxiety. In this study, we examined whether self-report, observer report, and behavioral and physiological reactivity were associated with each other during a speech challenge task. A total of 95 university students completed a self-report measure of public speaking anxiety before and after the speech challenge. Speech duration (i.e., behavioral measure), physiological reactivity, as well as speech performance evaluated by the participants and observers were also recorded. The results suggest that self-reported public speaking anxiety predicts speech duration, as well as speech quality, as rated by the participants themselves and observers. However, the physiological measures were not associated with self-reported anxiety during the speech task. Additionally, we observed that socially anxious participants underrate their speech performance in comparison to their observers' evaluations.

Are Pacing Patterns Really Based on Value Goals? Exploring the Contextual Role of Pain Acceptance and Pain Catastrophizing in Women with Fibromyalgia

Pain catastrophizing and pain acceptance have been associated with functioning in fibromyalgia. In relation to activity patterns, pacing has been defined as a helpful pattern to regulate activities in the context of value-based goals, but results regarding whether it is adaptive or not are controversial. This study analyzes the moderating role of pain acceptance between pain catastrophizing and pacing in 231 women with fibromyalgia. Moderation analyses were conducted with model 1 from the PROCESS Macro version 3.4. The results showed a clear moderating effect of pain acceptance. At low levels of pain acceptance, catastrophizing and pacing patterns maintained significant and positive associations. However, at high levels of pain acceptance, pacing was independent of catastrophizing. Far from considering pacing patterns as functional or dysfunctional per se, our results suggest that women with low pain acceptance carry out pacing influenced by catastrophizing independently of their goal pursuit, while patients who accept their pain may use pacing as a regulatory mechanism according to their goals.

Dialectical behaviour therapy skills training for the treatment of addictive behaviours among individuals with alcohol use disorder: the effect of emotion regulation and experiential avoidance

BACKGROUNDS

Dialectical behavior therapy skills training (DBT-ST) is an effective treatment for alcohol use disorder (AUD). AUD frequently co-occurs with other addictive behaviors.

OBJECTIVE

s: These secondary analyses of prior studies on the effectiveness of a 3-month DBT-ST program for AUD investigated pre- post-treatment changes in the severity of concurrent addictive behaviors. The study hypothesized that emotion regulation and experiential avoidance should be the key therapeutic mechanisms involved in the treatment of addictive behaviors.

METHODS

The research included 186 individuals (110 males; 76 females) with a primary diagnosis of AUD. Mediational models were performed considering shorter PROMIS questionnaire subscales (i.e., gambling, sex, shopping, food binging, and starvation) as dependent variables. The difficulties in emotion regulation scale and acceptance and action questionnaire-II total scores were independent and mediator variables, respectively.

RESULTS

Clinical variables significantly improved during the treatment, independent of baseline levels. Changes in emotion regulation showed significant total effects on improvements in addictive behaviors. Significant indirect effects of changes in experiential avoidance were detected considering compulsive buying and dysfunctional eating behaviors.

CONCLUSION

The DBT-ST was a feasible treatment for several addictive behaviors frequently reported by individuals with AUD. The improvements in emotion regulation and experiential avoidance were relevant therapeutic mechanisms involved in the treatment of these conditions. Future controlled trials and follow-up studies are recommended to support the efficacy of DBT-ST as a stand-alone intervention for the treatment of different classes of addictive behaviors.

Effect of Acceptance versus Attention on Pain Tolerance: Dissecting Two Components of Mindfulness

OBJECTIVES

Previous studies have shown that brief mindfulness trainings can have significant analgesic effects. However, the effects of the various components of mindfulness on pain analgesia are not well understood. The objective of this study was to examine the effects of two components of mindfulness interventions - attention and acceptance on pain analgesia.

METHODS

One hundred and nineteen healthy college students without prior mindfulness experience underwent a cold pressor test to measure pain tolerance before and after the training. Pain intensity, tolerance, distress, threshold and endurance time were also tested. Participants were randomly assigned to one of four conditions: (1) acceptance of pain, (2) attention to pain, (3) acceptance of and attention to pain, or (4) control.

RESULTS

The results showed that both the acceptance strategy and the combined acceptance and attention group increased pain endurance and tolerance after training. Furthermore, acceptance group had longer pain endurance time and tolerance time than attention group and control group.

CONCLUSIONS

These results suggest that acceptance of pain is more important than attention to pain. Study limitations and future research directions are discussed.

Food Cravings and Eating: The Role of Experiential Avoidance

Food cravings have been associated with problematic eating behaviors, such as emotional eating. Late adolescence is an important developmental period to examine this association, as late adolescents have greater independence in food choices as well as potentially higher demands during a transitional period of their lives. Mechanisms underlying the association between food cravings and problematic eating remain unclear. This study examined whether experiential avoidance (EA) may be one possible mechanism mediating the association between higher levels of food cravings and problematic eating behaviors. Late adolescents (n = 174) completed measures assessing EA, food cravings, and three problematic eating behaviors: emotional eating, cognitive restraint, and uncontrolled eating. Height and weight were measured objectively to calculate body mass index (BMI). Food cravings were positively associated with emotional eating and mediated by EA. EA also significantly mediated the association between greater cognitive restraint and greater food cravings. No significant mediation was detected for food cravings and uncontrolled eating. Future research may consider EA as a treatment target in intervention strategies for late adolescents seeking to decrease emotional or restrained eating behaviors.

The effect of passive heat stress on distress andself-control in male smokers and non-smokers

In the current study, we tested the effects of core body temperature increases (e.g. heat stress) on affect, self-reported physical discomfort, and subsequent self-control in male smokers and nonsmokers using a novel passive heat stress paradigm, within a distress tolerance framework. Twenty-eight men (14 smokers), completed both heat stress and control sessions in randomized order. Results revealed that increases in core body temperature were associated with increased anxiety, irritability, and body discomfort as well as decreased happiness, with stronger effects for smokers. Smokers and nonsmokers both evidenced less self-control during the heat session and did not differ on this measure, nor on a measure of interoceptive sensitivity. The current study indicates that heat stress is a viable method for studying distress tolerance in men, and suggests the value in examining dynamic changes in self-control as a function of distress. Implications will be discussed for distress tolerance in general and smokers in specific.

The Influence of a Personal Values Intervention on Cold Pressor-Induced Distress Tolerance

Research has demonstrated that values and acceptance interventions can increase distress tolerance, but the individual contribution of each remains unclear. The current study examined the isolated effect of a values intervention on immersion time in a cold pressor. Participants randomized to Values (n = 18) and Control (n = 14) conditions completed two cold pressor tasks, separated by a 30-min values or control intervention. Immersion time increased 51.06 s for participants in the Values condition and decreased by 10.79 s for those in the Control condition. Increases in self-reported pain and distress predicted decreases in immersion time for Control, but not Values, participants. The best-fitting model accounted for 39% of the variance in immersion time change. Results suggest that a brief isolated values exercise can be used to improve distress tolerance despite increased perceptions of pain and distress, such that values alone may be sufficient to facilitate openness to difficult experiences.

Identification and Characterization of Unique Subgroups of Chronic Pain Individuals with Dispositional Personality Traits

Objective. The current study attempted to identify and characterize distinct CP subgroups based on their level of dispositional personality traits. The secondary objective was to compare the difference among the subgroups in mood, coping, and disability. Methods. Individuals with chronic pain were assessed for demographic, psychosocial, and personality measures. A two-step cluster analysis was conducted in order to identify distinct subgroups of patients based on their level of personality traits. Differences in clinical outcomes were compared using the multivariate analysis of variance based on cluster membership. Results. In 229 participants, three clusters were formed. No significant difference was seen among the clusters on patient demographic factors including age, sex, relationship status, duration of pain, and pain intensity. Those with high levels of dispositional personality traits had greater levels of mood impairment compared to the other two groups (p < 0.05). Significant difference in disability was seen between the subgroups. Conclusions. The study identified a high risk group of CP individuals whose level of personality traits significantly correlated with impaired mood and coping. Use of pharmacological treatment alone may not be successful in improving clinical outcomes among these individuals. Instead, a more comprehensive treatment involving psychological treatments may be important in managing the personality traits that interfere with recovery.

Cognitive-Behavioral Therapy: How Medical Providers Can Increase Patient and Family Openness and Access to Evidence-Based Multimodal Therapy for Pediatric Migraine

Although evidence supports the recommendation for cognitive-behavioral therapy (CBT) for pediatric migraine, few children actually receive this evidence-based intervention. In this article, we briefly review the most recent empirical evidence supporting CBT. We then identify both provider- and system-related barriers as well as patient-related barriers. Finally, we provide practical solutions to addressing these barriers in the service of facilitating children receiving optimal comprehensive management of their headaches.

Mindfulness-Based Stress Reduction in Advanced Nursing Practice: A Nonpharmacologic Approach to Health Promotion, Chronic Disease Management, and Symptom Control

The aim of this article is to discuss how advanced practice nurses (APNs) can incorporate mindfulness-based stress reduction (MBSR) as a nonpharmacologic clinical tool in their practice. Over the last 30 years, patients and providers have increasingly used complementary and holistic therapies for the nonpharmacologic management of acute and chronic diseases. Mindfulness-based interventions, specifically MBSR, have been tested and applied within a variety of patient populations. There is strong evidence to support that the use of MBSR can improve a range of biological and psychological outcomes in a variety of medical illnesses, including acute and chronic pain, hypertension, and disease prevention. This article will review the many ways APNs can incorporate MBSR approaches for health promotion and disease/symptom management into their practice. We conclude with a discussion of how nurses can obtain training and certification in MBSR. Given the significant and growing literature supporting the use of MBSR in the prevention and treatment of chronic disease, increased attention on how APNs can incorporate MBSR into clinical practice is necessary.

Psychological flexibility in migraine: A study of pain acceptance and values-based action

Background

Studies of musculoskeletal pain patients confirm that acceptance of pain and values-based action are strong predictors of pain-related disability and that interventions fostering “psychological flexibility” confer positive outcomes. However, data on these processes in migraine remain limited. This cross-sectional study examined relations between components of psychological flexibility and headache among treatment-seeking migraineurs.

Methods

A total of 103 adults ( M age = 41.5 (11.9) years; 88.2% female) with ICHD-confirmed migraine (71.8% episodic, 28.2% chronic) across three clinics completed measures of psychological flexibility and headache-related disability. Hierarchical regressions quantified relations between acceptance/values-based action and headache variables after first controlling for pain severity and gender.

Results

Acceptance of pain and values-based action accounted for 10% of unique variance in headache severity (Δ R2 p = 0.006) and up to 20% in headache-related disability (Δ R2 ps = 0.02 and < 0.001) but were weakly related to headache frequency. Psychological flexibility was more strongly associated with MIDAS-measured disability than was headache severity or headache frequency. Significant effects were typically of medium-to-large size and driven primarily by values-based action.

Conclusions

Paralleling results from the broader chronic pain literature, pain acceptance and values-based action play significant roles in headache pain and disability. Further study of interventions targeting these processes may enhance existing treatments.

First evidence of a prospective relation between avoidance of internal states and borderline personality disorder features in adolescents

At least two leading developmental models of borderline personality disorder (BPD) emphasize the role of accurate reflection and understanding of internal states as significant to the development of BPD features (Fonagy, Int J Psycho-Anal 72:639-656, 1991; Linehan, Cognitive-behavioral treatment of borderline personality disorder, 1993). The current study used the construct of experiential avoidance (EA) to operationalize avoidance of internal states and sought to examine (1) the concurrent relations between EA and borderline features in a large and diverse community sample; and (2) the prospective relation between EA and borderline features over a 1-year follow-up, controlling for baseline levels of borderline features. N = 881 adolescents recruited from public schools in a large metropolitan area participated in baseline assessments and N = 730 completed follow-up assessments. Two main findings were reported. First, EA was associated with borderline features, depressive, and anxiety symptoms at the bivariate level, but when all variables were considered together, depression and anxiety no longer remained significantly associated with borderline features, suggesting that the relations among these symptom clusters may be accounted for by EA as a cross-cutting underlying psychological process. Second, EA predicted levels of borderline symptoms at 1-year follow-up, controlling for baseline levels of borderline symptoms, and symptoms of anxiety and depression. Results are interpreted against the background of developmental theories of borderline personality disorder.

Mindful Creativity Scale (MCS): Validation of a German version of the Langer Mindfulness Scale with patients with severe TBI and controls

BACKGROUND

Mindfulness may have an impact on the recovery process in patients who have suffered severe traumatic brain injury (TBI). In order to make an instrument for measuring mindfulness within the German speaking clinical community available, a short, easily usable scale and a cross-cultural adaptation is needed.

OBJECTIVES

To validate the Langer Mindfulness Scale (LMS) with German-speaking patients with severe TBI and their relatives (healthy controls).

RESEARCH DESIGN

In a prospective cohort study of patients with severe TBI, test-re-test interviews were carried out at 6-month intervals.

SAMPLE

A total of 225 participants responded to the first survey and 230 completed the second survey.

MEASURES

LMS, self-report questions on personality, openness and attention, as well as health and clinical evaluations (including cognitive and behavioural assessments).

RESULTS

On the basis of factor analysis, principal component analysis and item response analysis, the initial 21-items were reduced to six items. The resulting unidimensional scale showed high internal consistency (α = 0.82) and good test-re-test reliability (intra-class correlation for total score = 0.46). External validity was confirmed for the entire sample.

CONCLUSION

It was concluded that the German short form of the original LMS (MCS) is a valid and reliable measure of mindful creativity.

Mieux vivre avec la douleur chronique grâce à la thérapie d’acceptation et d’engagement

Cet article vise à présenter les particularités de la thérapie d’acceptation et d’engagement (Acceptance and Commitment Therapyou « ACT ») dans l’intervention auprès de patients souffrant de douleur chronique. Il décrit le contexte historique du développement des thérapies comportementales et cognitives dans ce domaine et présente les fondements théoriques de l’ACT. Il introduit les composantes d’une intervention basée sur l’acceptation et la pleine conscience en visitant plusieurs concepts du modèle de la flexibilité psychologique. Enfin, il synthétise un certain nombre de données probantes provenant des études expérimentales, corrélationnelles et cliniques qui appuient l’utilisation de l’ACT dans le domaine de la douleur chronique.

The benefits of being mindful: trait mindfulness predicts less stress reactivity to suppression

BACKGROUND AND OBJECTIVES

There has been a recent proliferation of research evaluating the efficacy of mindfulness as a clinical intervention. However, there is still little known about trait mindfulness, or how trait mindfulness interacts with maladaptive emotion regulation strategies. The current study further explores the effect of trait mindfulness on emotion regulation, as well as whether specific factors of trait mindfulness are uniquely associated with subjective and autonomic reactivity to stress.

METHODS

Forty-eight healthy male participants were trained in the use of the suppression strategy and then instructed to suppress their responses to the inhalation of a 15% CO2-enriched air mixture for 90 s while their subjective distress and heart rate were recorded.

RESULTS

After controlling for anxiety-related variables, the ability to provide descriptions of observed experiences predicted less heart rate reactivity to CO2 inhalation, while skillfulness at restricting attention to the present moment was uniquely predictive of less subjective distress. The tendency to attend to bodily or sensory stimuli predicted greater distress during CO2 inhalation.

LIMITATIONS

The inclusion of only healthy males limits the generalizability of study findings. Also, the sample size was relatively small.

CONCLUSIONS

These findings suggest that factors associated with trait mindfulness predict less stress reactivity and distress while engaging in suppression above and beyond other variables that have been shown to predict anxious responding. The implications for emotion and clinical research are discussed.

Disposition and adjustment to chronic pain

Several empirical studies have shown that personal characteristics act as differential variables, which determine how pain is experienced and how the chronic pain patient adjusts to pain. The main aim of the present research is to review the relationships between some dispositional characteristics and pain adjustment. Taking into account the empirical literature, 6 personality traits that are relevant to the pain experience have been selected: neuroticism, anxiety sensitivity, and experiential avoidance as risk factors that increase the probability of patients experiencing a disability; and extraversion, optimism, and resilience as personal resources that increase their capacity to manage pain effectively. The results suggest that it would be useful to include an assessment of normal personality structure during the multi-dimensional evaluation of a person with chronic pain. Understanding these individual personality characteristics will aid in designing pain intervention programs and help predict possible treatment outcomes.

Acceptance and related processes in adjustment to chronic pain

Chronic pain poses significant challenges in the lives of many people. At the root of many of these challenges are the behavior patterns pain naturally coordinates. For example, in some cases, attempts to control, reduce, or cure pain through medication, medical procedures, or lifestyle changes can prove unsuccessful, and can dominate all other potential goals. The experience of chronic pain also includes other discouraging, painful, or unwanted psychological experiences, such as thoughts, feelings, and memories. Attempts to control or reduce some of these psychological experiences also can prove unsuccessful and even harmful, further reducing quality of life. This review highlights recent evidence for the utility of acceptance as an alternative when control-based methods are unsuccessful. It describes evidence from experimental, clinical, and treatment outcome studies. The review also notes how work in this area is drawing attention to the wider concept of "psychological flexibility," an overarching process that includes other component processes, such as mindfulness and values.

Is distraction less effective when pain is threatening? An experimental investigation with the cold pressor task

Distraction is a commonly used strategy to control pain. However there is doubt about its effectiveness as a clinical tool, and results from both experimental and clinical studies remain inconclusive. Recent theoretical advancements suggest that distraction of attention may be less effective when pain is threatening. The aim of the present study was to experimentally investigate this hypothesis. Pain-free volunteers (N=101) participated in a cold pressor test. Half of the participants simultaneously performed a cognitive distraction task, the other half did not. The threat value of the pain was manipulated by means of verbal information. The results showed that distraction resulted in less attention to the pain and lower pain ratings once the cold pressor procedure was halted. The hypothesis that the effectiveness of distraction is modulated by the threat value of pain could not be confirmed. However, threatening information increased catastrophic thoughts and anxiety, and interfered with performance on the distraction task. These findings suggest that caution is required in using distraction as a pain control strategy when the threat value is high, because fearful appraisal of pain is associated with less engagement in distraction tasks.

Experiential avoidance and anxiety sensitivity as dispositional variables and their relationship to the adjustment to chronic pain

Anxiety sensitivity has been included in the fear-avoidance model as a vulnerability factor to explain individual differences in fear of pain. Several studies have suggested that the relationship between anxiety sensitivity and some psychopathological disorders is mediated by experiential avoidance, an affect-related regulatory process that involves unwillingness to endure private experiences. The role of these constructs as vulnerability variables has not been investigated in chronic pain patients. The aim of this study was to investigate the role of anxiety sensitivity and experiential avoidance as dispositional variables in pain fear-avoidance. Two alternative hypothetical models were tested: one in which anxiety sensitivity and experiential avoidance would be independently associated with pain fear-avoidance; and second, one in which experiential avoidance would mediate the relationship between anxiety sensitivity and pain fear-avoidance. The sample was composed of 299 patients with chronic back pain. The postulated relationships were tested using LISREL 8.20 software (Scientific Software International, Chicago, IL, USA) and the generally weighted least squares. The structural equation modelling analyses showed that experiential avoidance and anxiety sensitivity were independently associated with pain fear-avoidance and that anxiety sensitivity had a stronger association with pain fear-avoidance than experiential avoidance. The alternative model, in which experiential avoidance mediates the relationship between anxiety sensitivity and pain fear-avoidance, gave a much worse fit. These results highlight the importance of both anxiety sensitivity and experiential avoidance as variables which could explain individual differences in pain fear-avoidance. Thus, in terms of prevention, it should be a priority to identify patients with increased anxiety sensitivity and experiential avoidance during the first stages of the development of chronic pain conditions.

Examination of mask disturbance behavior during a carbon dioxide-enriched air challenge

BACKGROUND AND OBJECTIVES

The present investigation examined mask disturbance behavior in the context of a biological challenge.

METHOD

Participants included 128 adults (63.3% women; M(age) = 23.2, SD = 8.9) who underwent a 10% carbon dioxide-enriched air challenge.

RESULTS

Mask disturbance behavior, including complete or partial mask removal, was common during the challenge. Moreover, mask removal behavior during the challenge was significantly related to a greater increase in anxiety pre- to post-challenge, as well as greater levels of self-reported avoidance of a future challenge administration. However, mask touching and lifting behaviors were not related to other challenge criterion variables.

LIMITATIONS

The current study consisted primarily of young adults and did not include individuals with a panic disorder diagnosis. Replication and extension of the current findings is recommended.

CONCLUSIONS

Results suggest that mask removal behavior during the challenge may represent a possible behavioral marker of panic-relevant risk, although further work is necessary to determine its usefulness as a challenge measure.

Neurobiology of aversive states

Hoebel and colleagues are often known as students of reward and how it is coded in the CNS. This article, however, attempts to focus on the significant advances by Hoebel and others in dissecting out behavioral components of distinct aversive states and in understanding the neurobiology of aversion and the link between aversive states and addictive behaviors. Reward and aversion are not necessarily dichotomous and may reflect an affective continuum contingent upon environmental conditions. Descriptive and mechanistic studies pioneered by Bart Hoebel have demonstrated that the shift in the reward-aversion spectrum may be, in part, a result of changes in central dopamine/acetylcholine ratio, particularly in the nucleus accumbens. The path to aversion appears to include a specific neurochemical signature: reduced dopamine release and increased acetylcholine release in "reward centers" of the brain. Opioid receptors may have a neuromodulatory role on both of these neurotransmitters.

Interrelating Behavioral Measures of Distress Tolerance with Self-Reported Experiential Avoidance

Experiential avoidance and distress intolerance play a central role in novel behavior therapies, yet they appear to overlap considerably the REBT concept of low frustration tolerance. Using baseline data from 100 adult cigarette smokers enrolled in a clinical trial of smoking cessation therapies, the present study evaluated the convergent validity of common questionnaire measures of experiential avoidance (Acceptance and Action Questionnaire; AAQ; Hayes et al. 2004, and Avoidance and Inflexibility Scale: AIS; Gifford et al. 2004) and behavioral measures of distress tolerance (computerized Mirror Tracing Persistence Task: MTPT-C: Strong et al. 2003; computerized Paced Auditory Serial Addition Task; PASAT-C; Lejuez et al. 2003). The distress tolerance measures correlated significantly (r = .29) with one another. However, the questionnaire measures of experiential avoidance did not correlate with each other, nor with the behavioral measures. Further research is needed on the validity of measuring experiential avoidance by self-report and of the overlap versus distinctiveness of seemingly similar constructs such as experiential avoidance, distress tolerance, and frustration tolerance.

An experimental investigation of emotional willingness and physical pain tolerance in deliberate self-harm: the moderating role of interpersonal distress

Although theoretical and clinical literature emphasize the role of both an unwillingness to experience emotional distress and physical pain tolerance in deliberate self-harm (DSH), research on their associations with DSH remains limited. This study sought to examine the relationships between DSH and the willingness to experience emotional distress and tolerate physical pain, including the moderating role of interpersonal distress in these relationships. To this end, young adults with recent DSH (n = 43) and controls without any DSH (n = 52) were randomly assigned to 1 of 2 emotion-induction conditions (distressing or neutral), after which behavioral measures of both the willingness to experience distress and physical pain tolerance were obtained. Consistent with hypotheses, findings indicated heightened physical pain tolerance among self-harming individuals only under conditions of interpersonal distress. Furthermore, findings provided some support for the hypothesized association between DSH and the unwillingness to experience emotional distress, suggesting that self-harming women evidence less willingness to experience emotional distress only under conditions of depleted regulatory capacity (eg, following an interpersonal stressor).

The Impact of Experiential Avoidance on the Inference of Characters' Emotions: Evidence for an Emotional Processing Bias

Experiential avoidance is a functional class of maladaptive strategies that contribute to the development and maintenance of psychopathology. Although previous research has demonstrated group differences in the interpretation of aversive stimuli, there is limited work on the influence of experiential avoidance during the online processing of emotion. An experimental design investigated the influence of self-reported experiential avoidance during emotion processing by assessing emotion inferences during the comprehension of narratives that imply different emotions. Results suggest that experiential avoidance is partially characterized by an emotional information processing bias. Specifically, individuals reporting higher experiential avoidance scores exhibited a bias towards activating negative emotion inferences, whereas individuals reporting lower experiential avoidance scores exhibited a bias towards activating positive emotion inferences. Minimal emotional inference was observed for the non-bias affective valence. Findings are discussed in terms of the implications of experiential avoidance as a cognitive vulnerability for psychopathology.

Acceptance: An Historical and Conceptual Review

Recognition of the value of acceptance of the self, others, and the flux of human experience, has philosophical and religious roots that date back thousands of years. The past two decades have witnessed a swell of interest in acceptance, as evidenced by an increase in acceptance-based therapeutic interventions, and a growing appreciation of the paradoxical nature of acceptance and personal change and the role of experiential avoidance in psychopathology. In this article we review historical and contemporary descriptions and definitions of acceptance, measures of acceptance, the relation between acceptance and change, and the role of acceptance in psychopathology and psychotherapy. Our central objective is to delineate a rich conceptual scheme that encompasses the diverse ways in which acceptance has been explicated in classical and contemporary writings, and to highlight the need for further validation of this useful and popular construct.

Distress tolerance and psychopathological symptoms and disorders: a review of the empirical literature among adults

We review theory and empirical study of distress tolerance, an emerging risk factor candidate for various forms of psychopathology. Despite the long-standing interest in and promise of work on distress tolerance for understanding adult psychopathology, there has not been a comprehensive review of the extant empirical literature focused on the construct. As a result, a comprehensive synthesis of theoretical and empirical scholarship on distress tolerance, including integration of extant research on the relations between distress tolerance and psychopathology, is lacking. Inspection of the scientific literature indicates that there are a number of promising ways to conceptualize and measure distress tolerance, as well as documented relations between distress tolerance factors and psychopathological symptoms and disorders. Although promising, there also is notable conceptual and operational heterogeneity across the distress tolerance literature. Moreover, a number of basic questions remain unanswered regarding the associations between distress tolerance and other risk and protective factors and processes, as well as its putative role(s) in vulnerability for and resilience to psychopathology. Thus, the current article provides a comprehensive review of past and contemporary theory and research and proposes key areas for future empirical study of this construct.

Development of an acceptance-based coping intervention for alcohol dependence relapse prevention

Both psychological and neurobiological findings lend support to the long-standing clinical observation that negative affect is involved in the development and maintenance of alcohol dependence, and difficulty coping with negative affect is a common precipitant of relapse after treatment. Although many current approaches to relapse prevention emphasize change-based strategies for managing negative cognitions and affect, acceptance-based strategies for preventing relapse to alcohol use are intended to provide methods for coping with distress that are fundamentally different from, though in theory complementary to, approaches that emphasize control and change. This paper describes the development of Acceptance-Based Coping for Relapse Prevention (ABCRP), a new intervention for alcohol-dependent individuals who are within 6 months of having quit drinking. Results of preliminary testing indicate that the intervention is feasible with this population; and a small uncontrolled pilot study (N = 23) showed significant (P < .01) improvements in self-reported negative affect, emotional reactivity, perceived stress, positive affect, psychological well-being, and mindfulness level, as well as a trend (P = .06) toward reduction in craving severity between pre- and postintervention assessments. The authors conclude that this acceptance-based intervention seems feasible and holds promise for improving affect and reducing relapse in alcohol-dependent individuals, warranting further research.

Psychological flexibility as a fundamental aspect of health

Traditionally, positive emotions and thoughts, strengths, and the satisfaction of basic psychological needs for belonging, competence, and autonomy have been seen as the cornerstones of psychological health. Without disputing their importance, these foci fail to capture many of the fluctuating, conflicting forces that are readily apparent when people navigate the environment and social world. In this paper, we review literature to offer evidence for the prominence of psychological flexibility in understanding psychological health. Thus far, the importance of psychological flexibility has been obscured by the isolation and disconnection of research conducted on this topic. Psychological flexibility spans a wide range of human abilities to: recognize and adapt to various situational demands; shift mindsets or behavioral repertoires when these strategies compromise personal or social functioning; maintain balance among important life domains; and be aware, open, and committed to behaviors that are congruent with deeply held values. In many forms of psychopathology, these flexibility processes are absent. In hopes of creating a more coherent understanding, we synthesize work in emotion regulation, mindfulness and acceptance, social and personality psychology, and neuropsychology. Basic research findings provide insight into the nature, correlates, and consequences of psychological flexibility and applied research provides details on promising interventions. Throughout, we emphasize dynamic approaches that might capture this fluid construct in the real-world.

Discomfort intolerance: evaluation of incremental validity for panic-relevant symptoms using 10% carbon dioxide-enriched air provocation

The present investigation examined the relation between discomfort intolerance and panic-relevant symptoms among 216 (117 women) young adults who participated in a biological challenge procedure. Partially consistent with hypotheses, after covarying for anxiety sensitivity, negative affectivity, and emotional acceptance, the intolerance subscale of the Discomfort Intolerance scale [DIS; Schmidt, N. B., Richey, J. A., & Fitzpatrick, K. K. (2006). Discomfort intolerance: development of a construct and measure relevant to panic disorder. Journal of Anxiety Disorders, 20, 263-280] was significantly incrementally related to increased post-challenge anxiety focused on bodily sensations, physical panic symptoms, and behavioral avoidance, but not cognitive panic symptoms. Inconsistent with prediction, the avoidance subscale of the DIS was not significantly related to any of the dependent variables. Results are discussed in relation to better understanding the role of discomfort intolerance as a unique explanatory factor in the context of panic psychopathology.

Associations between emotional avoidance, anxiety sensitivity, and reactions to an observational fear challenge procedure

Research has shown that emotional avoidance and anxiety sensitivity are associated with more self-reported fear and distress in response to laboratory fear challenge procedures. The present study aimed to expand upon this work and examined how emotional avoidance and anxiety sensitivity are related to emotional and physiological responses to an observational fear challenge procedure. To accomplish this aim, a carefully screened, non-clinical sample (N=43) was administered the Acceptance and Action Questionnaire (AAQ), a measure of emotional avoidance, and the Anxiety Sensitivity Index (ASI). Participants then engaged in an observational fear challenge paradigm. During the fear challenge, participants watched mock panic attacks while emotional (e.g., fear and panic) and skin conductance levels were assessed. Consistent with expectation, emotional avoidance and anxiety sensitivity were positively associated with more self-reported fear and more severe panic symptoms to the challenge procedure. However, anxiety sensitivity was more highly associated with self-reported fear and panic symptoms in response to the challenge procedure than emotional avoidance. Emotional avoidance and anxiety sensitivity were not associated with levels of physiological arousal to the observational fear challenge procedure. Discussion focuses on the interplay between emotional avoidance, anxiety sensitivity, and the development of vicarious fear responses and how these constructs may contribute to the pathogenesis of anxiety disorders.

A comparison of laboratory measures of escape and avoidance behavior

Escape and avoidance of the onset of pain and exacerbations of pain can be difficult to distinguish in certain circumstances. This investigation compared measures of participants' (N = 61, 50.8% women) escape and avoidance behavior during an ischemic pain task. Instructions for the ischemic task were manipulated so that one group stopped the task whenever they wanted (eg, before the onset of pain) and another group endured the ischemic pain to tolerance. Delay time before beginning the task and willingness to complete the task were not related to self-reported escape/avoidance (r = -.21, P = .10; r = -.14, P = .30). Also, they were not predicted by fear, anxiety, or catastrophizing. Task duration with the unrestricted stop rule was not related to self-reported escape/avoidance (r = -.13, P = .50) and was not predicted by fear, anxiety, or catastrophizing. However, task duration with the tolerance stop rule was associated with self-reported escape/avoidance (r = -.40, P = .02) and was predicted by catastrophizing (t(29) = -2.92, P < .01). Thus, evidence for the validity of task duration with a tolerance stop rule as a measure of escape from pain or avoidance of pain exacerbation was found.

PERSPECTIVE

Measures of avoidance of pain onset were not supported. However, task duration was a valid measure of escape from pain or avoidance of pain exacerbation with tolerance stop rules. Other measures of escape/avoidance behavior and participants' perceptions of stable or increasing pain level throughout a pain task should be examined.

Adjustment to chronic pain: the role of pain acceptance, coping strategies, and pain-related cognitions

BACKGROUND

Previous research has found that acceptance of pain is more successful than coping variables in predicting adjustment to pain.

PURPOSE

To compare the influence of acceptance, pain-related cognitions and coping in adjustment to chronic pain.

METHODS

One hundred seventeen chronic pain patients attending the Clinical Pain Unit were administered a battery of questionnaires assessing pain acceptance, active and passive coping, pain-related cognitions, and adjustment.

RESULTS

The influence of acceptance, coping, and cognition on all the adjustment variables was considered simultaneously via Structural Equation Modeling using LISREL 8.30 software. A multigroup analysis showed that the male and female samples did not significantly differ regarding path coefficients. The final model showed that acceptance of pain determined functional status and functional impairment. However, coping measures had a significant influence on measures of emotional distress. Catastrophizing self-statements significantly influenced reported pain intensity and anxiety; resourcefulness beliefs had a negative and significant influence on depression.

CONCLUSIONS

These findings suggest that acceptance may play a critical role in the maintenance of functioning and, with this aim, acceptance-based treatments are promising to avoid the development of disability. They also lend support to the role of control beliefs and of active coping to maintain a positive mood. Acceptance and coping are presented as complementary approaches.

Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain

Psychosocial treatments for chronic pain are effective. There is a need, however, to understand the processes involved in determining how these treatments contribute to behavior change. Control and acceptance strategies represent two potentially important processes involved in treatment, although they differ significantly in approach. Results from laboratory-based studies suggest that acceptance-oriented strategies significantly enhance pain tolerance and behavioral persistence, compared with control-oriented strategies. There is a need, however, to investigate processes of acceptance and control directly in clinical settings. The present study investigated the effects of three brief instructional sets (pain control, pain acceptance, continued practice) on demonstrated physical impairment in 74 individuals with chronic low back pain using an analogue experimental design. After controlling for baseline performance, the pain acceptance group demonstrated greater overall functioning on a set of 7 standardized physical tasks relative to the other two groups, which did not differ from one another. Further, the acceptance group exhibited a 16.3% improvement in impairment, whereas the pain control group worsened by 8.3% and the continued practice group improved by 2.5%. These results suggest that acceptance may be a key process involved in behavior change in individuals with chronic pain.