Can Experimentally Induced Positive Affect Attenuate Generalization of Fear of Movement-Related Pain?

Fear Learning in Genital Pain: Toward a Biopsychosocial, Ecologically Valid Research and Treatment Model

Although fear learning mechanisms are implicated in the development, maintenance, exacerbation, and reduction of genital pain, systematic research on how fear of genital pain emerges, spreads, persists, and reemerges after treatment is lacking. This paper provides an overview of the literature on pain-related fear, integrates the ideas on learning and sexual arousal responding, and specifies the pathways through which compromised learning may contribute to the development and persistence of genital pain. In order to refine theories of genital pain and optimize treatments, we need to adopt a biopsychosocial framework to pain-related fear learning and uncover potential moderators that shape individual trajectories. This involves examining the role of physiological processes, subjective experiences, as well as partner and relational cues in fear acquisition, excessive generalization and impaired safety learning, extinction of fear, counterconditioning, and return of fear. Recent methodological advances in fear conditioning and sex research are promising to enable more symptom-specific and ecologically valid experimental paradigms.

The influence of pain-related comorbidities on pain intensity and pain-related psychological distress in patients presenting with musculoskeletal pain

BACKGROUND

Musculoskeletal pain (MSP) is the largest contributor to chronic pain and frequently occurs alongside other medical comorbidities.

OBJECTIVE

Explore the relationships between the presence of pain-related comorbidities, pain intensity, and pain-related psychological distress in patients with MSP.

METHODS

A longitudinal assessment of individuals 18-90 years old in the Midwestern United States beginning a new episode of physical therapy for MSP. Electronic medical records were assessed the full year prior for care-seeking of diagnoses for pain-related comorbidities (anxiety, metabolic disorder, chronic pain, depression, nicotine dependence, post-traumatic stress disorder, sleep apnea, and sleep insomnia). Pain intensity and pain-related psychological distress (Optimal Screening for Prediction of Referral and Outcome - Yellow Flags tool) were captured during the physical therapy evaluation. Generalized linear models were used to assess the association between pain intensity, psychological distress, and pain-related co-morbidities. Models were adjusted for variables shown in the literature to influence pain.

RESULTS

532 participants were included in the cohort (56.4% female; median age of 59 years, Interquartile Range [IQR]:47, 69). Comorbid depression (beta coefficient (β) = 0.7; 95%CI: 0.2, 1.2), spine versus lower extremity pain ((β = 0.6; 95%CI: 0.1, 1.1), and prior surgery (β = 0.8, 95%CI: 0.3, 1.4) were associated with higher pain intensity scores. No pain-related comorbidities were associated with pain-related psychological distress (yellow flag count or number of domains). Female sex was associated with less pain-related psychological distress (β = -0.2, 95%CI: -0.3, -0.02).

CONCLUSIONS

Depression was associated with greater pain intensity. No comorbidities were able to account for the extent of pain-related psychological distress.

The effect of experimentally induced positive affect on the generalization of pain-related avoidance and relief

Avoiding pain-associated activities can prevent tissue damage. However, when avoidance spreads excessively (or overgeneralizes) to safe activities, it may culminate into chronic pain disability. Gaining insight into ways to reduce overgeneralization is therefore crucial. An important factor to consider in this is relief, as it reinforces avoidance behavior and therefore may be pivotal in making avoidance persist. The current study investigated whether experimentally induced positive affect can reduce generalization of pain-related avoidance and relief. We used a conditioning task in which participants (N = 50) learned that certain stimuli were followed by pain, while another was not. Subsequently, they learned an avoidance response that effectively omitted pain with one stimulus, but was ineffective with another. Next, one group of participants performed an exercise to induce positive affect, while another group performed a control exercise. During the critical generalization test, novel stimuli that were perceptually similar to the original stimuli were presented. Results showed that both avoidance and relief generalized to novel stimuli, thus replicating previous work. However, increasing positive affect did not reduce generalization of avoidance, nor relief.

Should cognitive restructuring precede imagery rescripting? An experimental pilot study

BACKGROUND AND OBJECTIVES

Imagery rescripting (ImRs) is a promising therapeutic technique used in treatment for a variety of psychiatric disorders. During an ImRs session, an aversive disorder-related memory, is activated in imagination and rescripted to a more positive outcome. It has been shown to successfully weaken the negative cognitive meaning, so-called encapsulated beliefs of the targeted aversive memory. In many studies, ImRs is preceded by a cognitive restructuring (CR) technique focused on the encapsulated belief of the target memory. It is not clear whether adding such a CR technique is necessary or that ImRs as standalone technique can achieve comparable effects.

METHODS

Students with mild psychological distress (N = 53) were randomized over one session of cognitive restructuring plus imagery rescripting (CR + ImRs), a therapist attention placebo plus imagery rescripting (PLA + ImRs) and a double therapist attention placebo (PLA + PLA). Believability of the idiosyncratic encapsulated belief (primary outcome) and quality (vividness, distress and emotional connotation: secondary outcome) of the target memory were assessed at pre, post and at 1-week follow-up.

RESULTS

Results indicate that both, CR + ImRs and PLA + ImRs, reduced the believability of the encapsulated beliefs in greater extent than PLA + PLA. No differences appeared between the two ImRs conditions. For the secondary outcomes no differences between the three conditions were found.

LIMITATIONS

This study should be seen as a pilot study, moreover a non-clinical sample was used.

CONCLUSION

Findings suggest that a CR technique preceding ImRs is redundant. However, this study needs replication in a larger sample.

Increased positive affect is associated with less generalization of pain-related avoidance

Fear-avoidance models of chronic pain consider excessive spreading (or overgeneralization) of pain-related avoidance toward safe activities to play a crucial role in chronic pain disability. This study (N = 96) investigated whether avoidance generalization is mitigated by positive affect induction. Pain-free, healthy participants performed an arm-reaching task during which certain movements were followed by pain, while another was not. One group then performed an exercise to induce positive affect (positive affect group), while another group performed a neutral exercise (neutral group). A third group also performed the neutral exercise, but did not learn to avoid pain during the arm-reaching task (yoked neutral group). To test generalization, we introduced novel but similar movements that were never followed by pain in all groups. Results showed no differences in generalization between the positive affect and neutral groups; however, across groups, higher increases in positive affect were associated with less generalization of avoidance, and less generalization of pain-expectancy and pain-related fear. Compared to the yoked neutral group, the neutral group showed avoidance generalization, as well as pain-expectancy and pain-related fear generalization. These results point toward the potential of positive affect interventions in attenuating maladaptive spreading of pain-related avoidance behavior to safe activities.

Resilience Interventions Conducted in Western and Eastern Countries-A Systematic Review

Previous research has demonstrated the efficacy of psychological interventions to foster resilience. However, little is known about whether the cultural context in which resilience interventions are implemented affects their efficacy on mental health. Studies performed in Western (k = 175) and Eastern countries (k = 46) regarding different aspects of interventions (setting, mode of delivery, target population, underlying theoretical approach, duration, control group design) and their efficacy on resilience, anxiety, depressive symptoms, quality of life, perceived stress, and social support were compared. Interventions in Eastern countries were longer in duration and tended to be more often conducted in group settings with a focus on family caregivers. We found evidence for larger effect sizes of resilience interventions in Eastern countries for improving resilience (standardized mean difference [SMD] = 0.48, 95% confidence interval [CI] 0.28 to 0.67; p < 0.0001; 43 studies; 6248 participants; I2 = 97.4%). Intercultural differences should receive more attention in resilience intervention research. Future studies could directly compare interventions in different cultural contexts to explain possible underlying causes for differences in their efficacy on mental health outcomes.

[A role of cognitive and emotional factors in formation of pain]

Pain is influenced by multiple emotional and cognitive factors. This paper provides an overview of the most important emotional and cognitive factors affecting pain, which has been confirmed in experimental and clinical studies. Emotional factors that increase pain perception include anxiety, depression, and other negative emotions. Positive emotions lead to a decrease in pain. Cognitive factors such as attention, expectation anxiety, and pain assessment can both increase and decrease pain sensations, depending on their specific focus. It becomes clear that pain is not just a reflection of nociceptive irritation, but also a feeling formed by psychological factors that can be individual in each case.

Optimizing Long-term Outcomes of Exposure for Chronic Primary Pain from the Lens of Learning Theory

Exposure in vivo is a theory-driven and widely used treatment to tackle functional disability in people with chronic primary pain. Exposure is quite effective; yet, in line with exposure outcomes for anxiety disorders, a number of patients may not profit from it, or relapse. In this focus article, we critically reflect on the current exposure protocols in chronic primary pain, and provide recommendations on how to optimize them. We propose several adaptations that are expected to strengthen inhibitory learning and/or retrieval of the extinction memory, thus likely decreasing relapse. We summarize the limited, but emerging experimental data in the pain domain, and draw parallels with experimental evidence in the anxiety literature. Our reflections and suggestions pertain to the use of the fear hierarchy, reassurance, positive psychology interventions, exposure with a range of stimuli and within different contexts, and the use of safety behaviors during treatment, as well as associating the fear-inducing stimuli with novel outcomes. In addition, we reflect on the importance of specifically tackling (the return of) pain-related avoidance behavior with techniques such as disentangling fear from avoidance and reinforcing approach behaviors. Finally, we discuss challenges in the clinical application of exposure to improve functioning in chronic primary pain and possible avenues for future research. Perspectives: Inspired by recent advances in learning theory and its applications on the treatment of anxiety disorders, we reflect on the delivery of exposure treatment for chronic primary pain and propose strategies to improve its long-term outcomes.

Will that hurt? A contingency learning task to assess pain-expectancy judgments for low back postures

BACKGROUND AND OBJECTIVES

Contingency learning, i.e. learning that a cue predicts the presence (or absence) of an event, is central to the formation of beliefs regarding painfulness of body postures. Such beliefs may spread to safe cues due to compromised learning (e.g., excessive generalization, impaired safety learning), prompting avoidance and leading to disability. Despite its importance, compromised learning about low back pain is underinvestigated. We propose a low back pain scenario contingency learning task for the investigation of back pain-related learning.

METHODS

Sixty healthy participants viewed pictures of an avatar in various back postures, and for each posture gave pain-expectancy judgments and viewed the verbal outcome (pain/no pain) for a fictive back pain patient. During acquisition, one posture was followed by pain (conditioned stimulus; CS+), whereas another was not (CS-). During generalization, unreinforced novel intermediate back postures (generalization stimuli; GSs) were tested. During extinction, only the CSs were presented, not followed by pain. During generalization of extinction, only the GSs were presented, not followed by pain.

RESULTS

Participants expected pain more for the CS + than the CS- (differential acquisition) and generalized their pain-expectancy to the GS most similar to the CS+ (generalization). During extinction, pain-expectancy for the CS + decreased and generalized to the GS most similar to the CS+ (generalization of extinction).

LIMITATIONS

Future research should investigate generalizability of findings to clinical samples and consider the role of pre-existing pain threat beliefs.

CONCLUSIONS

This task is an easily applicable, non-invasive way to investigate the formation of back pain-related threat beliefs.

Psychological interventions to foster resilience in healthcare students

BACKGROUND

Resilience can be defined as maintaining or regaining mental health during or after significant adversities such as a potentially traumatising event, challenging life circumstances, a critical life transition or physical illness. Healthcare students, such as medical, nursing, psychology and social work students, are exposed to various study- and work-related stressors, the latter particularly during later phases of health professional education. They are at increased risk of developing symptoms of burnout or mental disorders. This population may benefit from resilience-promoting training programmes.

OBJECTIVES

To assess the effects of interventions to foster resilience in healthcare students, that is, students in training for health professions delivering direct medical care (e.g. medical, nursing, midwifery or paramedic students), and those in training for allied health professions, as distinct from medical care (e.g. psychology, physical therapy or social work students).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any form of psychological intervention to foster resilience, hardiness or post-traumatic growth versus no intervention, waiting list, usual care, and active or attention control, in adults (18 years and older), who are healthcare students. Primary outcomes were resilience, anxiety, depression, stress or stress perception, and well-being or quality of life. Secondary outcomes were resilience factors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post-test only).

MAIN RESULTS

We included 30 RCTs, of which 24 were set in high-income countries and six in (upper- to lower-) middle-income countries. Twenty-two studies focused solely on healthcare students (1315 participants; number randomised not specified for two studies), including both students in health professions delivering direct medical care and those in allied health professions, such as psychology and physical therapy. Half of the studies were conducted in a university or school setting, including nursing/midwifery students or medical students. Eight studies investigated mixed samples (1365 participants), with healthcare students and participants outside of a health professional study field. Participants mainly included women (63.3% to 67.3% in mixed samples) from young adulthood (mean age range, if reported: 19.5 to 26.83 years; 19.35 to 38.14 years in mixed samples). Seventeen of the studies investigated group interventions of high training intensity (11 studies; > 12 hours/sessions), that were delivered face-to-face (17 studies). Of the included studies, eight compared a resilience training based on mindfulness versus unspecific comparators (e.g. wait-list). The studies were funded by different sources (e.g. universities, foundations), or a combination of various sources (four studies). Seven studies did not specify a potential funder, and three studies received no funding support. Risk of bias was high or unclear, with main flaws in performance, detection, attrition and reporting bias domains. At post-intervention, very-low certainty evidence indicated that, compared to controls, healthcare students receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.43, 95% confidence interval (CI) 0.07 to 0.78; 9 studies, 561 participants), lower levels of anxiety (SMD -0.45, 95% CI -0.84 to -0.06; 7 studies, 362 participants), and lower levels of stress or stress perception (SMD -0.28, 95% CI -0.48 to -0.09; 7 studies, 420 participants). Effect sizes varied between small and moderate. There was little or no evidence of any effect of resilience training on depression (SMD -0.20, 95% CI -0.52 to 0.11; 6 studies, 332 participants; very-low certainty evidence) or well-being or quality of life (SMD 0.15, 95% CI -0.14 to 0.43; 4 studies, 251 participants; very-low certainty evidence). Adverse effects were measured in four studies, but data were only reported for three of them. None of the three studies reported any adverse events occurring during the study (very-low certainty of evidence).

AUTHORS' CONCLUSIONS

For healthcare students, there is very-low certainty evidence for the effect of resilience training on resilience, anxiety, and stress or stress perception at post-intervention. The heterogeneous interventions, the paucity of short-, medium- or long-term data, and the geographical distribution restricted to high-income countries limit the generalisability of results. Conclusions should therefore be drawn cautiously. Since the findings suggest positive effects of resilience training for healthcare students with very-low certainty evidence, high-quality replications and improved study designs (e.g. a consensus on the definition of resilience, the assessment of individual stressor exposure, more attention controls, and longer follow-up periods) are clearly needed.

A novel virtual reality paradigm: Predictors for stress-related intrusions and avoidance behavior

BACKGROUND AND OBJECTIVES

Most people are exposed to a violent or life-threatening situation during their lives, but only a minority develops a stress-related disorder. To examine risk factors for the development of stress-related symptoms, such as intrusions and avoidance, analogue trauma studies are necessary. The often-used trauma film paradigm has proven to be valuable to examine intrusions, but inherently to its technique is less suitable for assessing behavioral avoidance, a core symptom of stress-related disorders. The aim of the present study was twofold, first to further develop an analogue that explicitly addresses behavioral avoidance and second, to link previously-established risk factors for the development of stress-related symptoms.

METHOD

Eighty-two healthy participants were subjected to a trauma induction using virtual reality (VR). At follow-up, participants were placed in a similar VR environment and could approach or avoid the trauma-scene, a trauma-related scene or a neutral, unrelated scene. Several pre- and peri-trauma risk factors were measured.

RESULTS

The VR paradigm increased negative mood and heart rate, decreased positive mood and heart rate variability, and resulted in stress-related symptoms as trauma-related thoughts and beliefs, intrusions and avoidance behavior. The most prominent risk factors that contributed to the stress-related symptoms were negative emotions during the trauma induction, trait anxiety, and avoidant coping strategies.

LIMITATIONS

The stress-related symptoms were mild, resulting in a vast amount of participants without intrusions and limited avoidance behavior.

CONCLUSION

The current VR paradigm can elicit stress-related symptoms, including avoidance; risk factors contributing to these symptoms were similar to those observed in clinical research, indicating the potential of the general set up.

Effects of the Best Possible Self intervention: A systematic review and meta-analysis

The Best Possible Self (BPS) exercise promotes a positive view of oneself in the best possible future, after working hard towards it. Since the first work that attempted to examine the benefits of this intervention in 2001, studies on the BPS have grown exponentially and, currently, this is one of the most widely used Positive Psychology Interventions. However, little is yet known about its overall effectiveness in increasing wellbeing outcomes. Thus, the aim of this meta-analysis is to shed light on this question. A systematic literature search was conducted, and 29 studies (in 26 articles) met the inclusion criteria of empirically testing the intervention and comparing it to a control condition. In addition, BPS was compared to gratitude interventions in some of the included studies. A total of 2,909 participants were involved in the analyses. The outcome measures were wellbeing, optimism, depressive symptoms, and positive and negative affect. Results showed that the BPS is an effective intervention to improve wellbeing (d+ = .325), optimism (d+ = .334) and positive affect (d+ = .511) comparing to controls. Small effect sizes were obtained for negative affect and depressive symptoms. Moderator analyses did not show statistically significant results for wellbeing, except for a trend towards significance in the age of the participants (years) and the magnitude of the intervention (total minutes of practice). In addition, the BPS was found to be more beneficial for positive and negative affect than gratitude interventions (d+ = .326 and d+ = .485, respectively). These results indicate that the BPS can be considered a valuable Positive Psychology Intervention to improve clients' wellbeing, and it seems that it might be more effective for older participants and with shorter practices (measured as total minutes of practice).

The relationship between fear generalization and pain modulation: an investigation in healthy participants

Background and aims

Pain-related fear and its subsequent generalization is key to the development and maintenance of chronic pain disability. Research has shown that pain-related fear acquired through classical conditioning generalizes following a gradient, that is, novel movements that are proprioceptively similar to the original pain-associated movement elicit more fear. Studies suggest that classical conditioning can also modulate pain and conditioned fear seems to mediate this effect. However, it remains uninvestigated whether this is also the case for generalized fear.

Methods

In a voluntary joystick movement paradigm, one movement (conditioned stimulus; CS+) was followed by pain (pain-US), and another was not (CS−). Generalization to five novel movements (generalization stimuli; GSs) with varying levels of similarity to the CSs was tested when paired with an at-pain-threshold intensity stimulus (threshold-USs). We collected self-reported fear and pain, as well as eyeblink startle responses as an additional index of conditioned fear.

Results

Results showed a fear generalization gradient in the ratings, but not in the startle measures. The data did not support the idea that fear generalization mediates spreading of pain.

Conclusions

Despite the lack of effects in the current study, this is a promising novel approach to investigate pain modulation in the context of chronic pain.

Implications

This study replicates the finding that pain-related fear spreads selectively towards movements that are proprioceptively more similar to the original pain-eliciting movement. Although results did not support the idea that such generalized fear mediates spreading of pain, the study provides a promising approach to investigate pain modulation by pain-associated movements.

The effect of differential spatiotopic information on the acquisition and generalization of fear of movement-related pain

Fear of movement-related pain significantly contributes to musculoskeletal chronic pain disability. Previous research has shown that fear of movement-related pain can be classically conditioned. That is, in a differential fear conditioning paradigm, after (repeatedly) pairing a neutral joystick movement (conditioned stimulus; CS+) with a painful stimulus (unconditioned stimulus; pain-US), that movement in itself starts to elicit self-reported fear and elevated psychophysiological arousal compared to a control joystick movement (CS−) that was never paired with pain. Further, it has been demonstrated that novel movements that are more similar to the original CS+ elicit more fear than novel movements that are more similar to the CS−, an adaptive process referred to as stimulus generalization. By default, movement/action takes place in reference to the three-dimensional space: a movement thus not only involves proprioceptive information, but it also contains spatiotopic information. Therefore, the aim of this study was to investigate to what extent spatiotopic information (i.e., endpoint location of movement) contributes to the acquisition and generalization of such fear of movement-related pain besides proprioception (i.e., movement direction). In a between-subjects design, the location group performed joystick movements from the middle position to left and right; the movement group moved the joystick from left and right to the middle. One movement (CS+) was paired with pain, another not (CS−). Feature overlap between CSs typically reduces differential learning. The endpoint of both CSs in the movement group is an overlapping feature whereas in the location group the endpoint of both CSs is distinct; therefore we hypothesized that there would be less differential fear learning in the movement group compared to the location group. We also tested generalization to movements with similar proprioceptive features but different endpoint location. Following the principle of stimulus generalization, we expected that novel movements in the same direction as the CS+ but with a different endpoint would elicit more fear than novel movement in the same direction of the CS− but with a different endpoint. Main outcome variables were self-reported fear and pain-US expectancy and eyeblink startle responses (electromyographic). Corroborating the feature overlap hypothesis, the location group showed greater differential fear acquisition. Fear generalization emerged for both groups in the verbal ratings, suggesting that fear indeed accrued to proprioceptive CS features; these effects, however, were not replicated in the startle measures.

Turning negative memories around: Contingency versus devaluation techniques

BACKGROUND AND OBJECTIVES

It is assumed that fear responses can be altered by changing the contingency between a conditioned stimulus (CS) and an unconditioned stimulus (US), or by devaluing the present mental representation of the US. The aim of the present study was to compare the efficacy of contingency- and devaluation-based intervention techniques on the diminishment in - and return of fear. We hypothesized that extinction (EXT, contingency-based) would outperform devaluation-based techniques regarding contingency measures, but that devaluation-based techniques would be most effective in reducing the mental representation of the US. Additionally, we expected that incorporations of the US during devaluation would result in less reinstatement of the US averseness.

METHODS

Healthy participants received a fear conditioning paradigm followed by one of three interventions: extinction (EXT, contingency-based), imagery rescripting (ImRs, devaluation-based) or eye movement desensitization and reprocessing (EMDR, devaluation-based). A reinstatement procedure and test followed the next day.

RESULTS

EXT was indeed most successful in diminishing contingency-based US expectancies and skin conductance responses (SCRs), but all interventions were equally successful in reducing the averseness of the mental US representation. After reinstatement EXT showed lowest expectancies and SCRs; no differences were observed between the conditions concerning the mental US representation.

LIMITATIONS

A partial reinforcement schedule was used, resulting in a vast amount of contingency unaware participants. Additionally, a non-clinical sample was used, which may limit the generalizability to clinical populations.

CONCLUSION

EXT is most effective in reducing conditioned fear responses.

Psychological Factors Associated with Phantom Limb Pain: A Review of Recent Findings

Phantom limb pain (PLP) is a common phenomenon occurring after the amputation of a limb and can be accompanied by serious suffering. Psychological factors have been shown to play an important role in other types of chronic pain, where they are pivotal in the acquisition and maintenance of pain symptoms. For PLP, however, the interaction between pain and psychological variables is less well documented. In this review, we summarize research on the role of emotional, motivational, cognitive, and perceptual factors in PLP. The reported findings indicate that emotional factors modulate PLP but might be less important compared to other types of chronic pain. Additional factors such as the amount of disability and adjustment to the amputation appear to also play a role. Bidirectional relationships between stress and PLP have been shown quite consistently, and the potential of stress and tension reduction in PLP treatment could be further exploited. Little is known about the role of cognitive variables such as attention or expectation. Catastrophizing seems to aggravate PLP and could be targeted in treatment. Body perception is altered in PLP and poses a potential target for novel mechanistic treatments. More research on psychological factors and their interactions in PLP is needed.

Positive affect skills may improve pain management in people with HIV

Non-opioid pain management strategies are critically needed for people with HIV. We therefore conducted a secondary analysis of pain-related outcomes in a randomized controlled trial of a positive affect skills intervention for adults newly diagnosed with HIV (N = 159). Results suggest that, even if pain prevalence rises, positive affect skills may reduce pain interference and prevent increased use of opioid analgesics by people living with HIV. Future research should replicate and extend these findings by conducting trials that are specifically designed to target pain outcomes.

Predictors and social consequences of daily pain expectancy among adults with chronic pain

Previous research suggests that for people living with chronic pain, pain expectancy can undermine access to adaptive resources and functioning. We tested and replicated the unique effect of pain expectancy on subsequent pain through 2 daily diary studies. We also extended previous findings by examining cognitive and affective antecedents of pain expectancy and the consequences of pain expectancy for daily social enjoyment and stress. In study 1, 231 individuals with rheumatoid arthritis completed 30 end-of-day diaries. Results of multilevel structural equation model showed that controlling for today's pain, pain expectancy predicted next day pain. In study 2, diary assessments of affective, cognitive, and social factors were collected during the morning, afternoon, and evening for 21 days from a sample of 220 individuals with fibromyalgia. Results showed that both positive affect and the extent to which pain interfered with daily activities in the afternoon predicted evening pain expectancy in the expected direction. However, negative affect and pain coping efficacy were not associated with pain expectancy. Consistent with study 1, more than usual evening pain expectancy was related to greater next morning pain. We also found that next morning pain predicted next afternoon social enjoyment but not social stress. The findings of these 2 studies point to the importance of promoting positive affect and reducing pain expectancy as a way of decreasing the detrimental effect of chronic pain on enjoyable social experiences.

Can positive affect attenuate (persistent) pain? State of the art and clinical implications

Purpose of Review

Pain is an intense experience that can place a heavy burden on peoples’ lives. The identification of psychosocial risk factors led to the development of effective pain treatments. However, effect sizes are modest. Accumulating evidence suggests that enhancing protective factors might also impact on (well-being despite) pain. Recent findings on positive affect (interventions) towards pain-related outcomes will be reviewed, and new avenues for treatment of persistent pain will be discussed.

Recent Findings

Positive affect significantly attenuates the experience of pain in healthy and clinical populations. Positive affect interventions effectively reduce pain sensitivity and bolster well-being despite pain. Through both psychological and (neuro-)biological pathways, but also through its effect on central treatment processes such as inhibitory learning, positive affect can optimize the efficacy of existing treatments.

Summary

Comprehensive understanding of the unique roles and dynamic interplay of positive and negative affect in moderating pain may optimize the treatment of (persistent) pain.

Towards a science and practice of resilience in the face of pain

The primary objective of this paper is to discuss how a resilience approach to (chronic) pain may advance our current understanding of (mal)adaptation to pain. Different resilience perspectives are described, and future challenges for research, prevention and treatment of (chronic) pain are discussed. Literature searches were performed in Web of Science and PubMed to identify relevant literature on risk and resilience in the context of pain. Resilience can be best defined as the ability to restore and sustain living a fulfilling life in the presence of pain. The Psychological Flexibility Model, the Broaden-and-Build Theory, and Self-Determination Theory are described as theories that may provide insight into resilience within the context of (chronic) pain. We describe how a resilience paradigm shifts the outcomes to pursue in pain research and intervention and argue the need for including positive outcomes in addition to negative outcomes. Psychological flexibility, positive affect and basic psychological needs satisfaction are described as potentially important resilience mechanisms with the potential to target both sustainability and recovery from pain. A resilience approach to chronic pain may have important implications for the prevention and treatment of chronic pain problems, as it may give specific indications on how to empower patients to continue living a fulfilling life (in the presence of pain).

SIGNIFICANCE

The resilience approach put forward in this review spotlights sustainability of positive outcomes (e.g. engagement in meaningful activities) in the presence of pain as an outcome to pursue beyond recovery of negative outcomes. We illuminate the evidence-base and practical application of promising resilience mechanisms (positive emotions, psychological flexibility, needs satisfaction). For this article, a commentary is available at the Wiley Online Library.

The Influence of State Anxiety on Fear Discrimination and Extinction in Females

Formal theories have linked pathological anxiety to a failure in fear response inhibition. Previously, we showed that aberrant response inhibition is not restricted to anxiety patients, but can also be observed in anxiety-prone adults. However, less is known about the influence of currently experienced levels of anxiety on inhibitory learning. The topic is highly important as state anxiety has a debilitating effect on cognition, emotion, and physiology and is linked to several anxiety disorders. In the present study, healthy female volunteers performed a fear conditioning task, after being informed that they will have to perform the Trier Social Stress Test task (n = 25; experimental group) or a control task (n = 25; control group) upon completion of the conditioning task. The results showed that higher levels of state anxiety corresponded with a reduced discrimination between a stimulus (CS+) typically followed by an aversive event and a stimulus (CS-) that is never followed by an aversive event both during the acquisition and the extinction phase. No effect of state anxiety on the skin conductance response associated with CS+ and CS- was found. Additionally, higher levels of state anxiety coincided with more negative valence ratings of the CSs. The results suggest that increased stress-induced state anxiety might lead to stimulus generalization during fear acquisition, thereby impairing associative learning.

Modification of Fear Memory by Pharmacological and Behavioural Interventions during Reconsolidation

Background

Dysfunctional fear responses play a central role in many mental disorders. New insights in learning and memory suggest that pharmacological and behavioural interventions during the reconsolidation of reactivated fear memories may increase the efficacy of therapeutic interventions. It has been proposed that interventions applied during reconsolidation may modify the original fear memory, and thus prevent the spontaneous recovery and reinstatement of the fear response.

Methods

We investigated whether pharmacological (propranolol) and behavioural (reappraisal, multisensory stimulation) interventions reduce fear memory, and prevent reinstatement of fear in comparison to a placebo control group. Eighty healthy female subjects underwent a differential fear conditioning procedure with three stimuli (CS). Two of these (CS+) were paired with an electric shock on day 1. On day 2, 20 subjects were pseudo-randomly assigned to either the propranolol or placebo condition, or underwent one of the two behavioural interventions after one of the two CS+ was reactivated. On day 3, all subjects underwent an extinction phase, followed by a reinstatement test. Dependent variables were US expectancy ratings, fear-potentiated startle, and skin conductance response.

Results

Differential fear responses to the reactivated and non-reactivated CS+ were observed only in the propranolol condition. Here, the non-reactivated CS+ evoked stronger fear-potentiated startle-responses compared to the placebo group. None of the interventions prevented the return of the extinguished fear response after re-exposure to the unconditioned stimulus.

Conclusions

Our data are in line with an increasing body of research stating that the occurrence of reconsolidation may be constrained by boundary conditions such as subtle differences in experimental manipulations and instructions. In conclusion, our findings do not support a beneficial effect in using reconsolidation processes to enhance effects of psychotherapeutic interventions. This implies that more research is required before therapeutic interventions may benefit from a combination with reconsolidation processes.

Development of a Yellow Flag Assessment Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort

Study Design Clinical measurement, cross-sectional. Background Pain-associated psychological distress adversely influences outcomes for patients with musculoskeletal pain. However, assessment of pain-associated psychological distress (ie, yellow flags) is not routinely performed in orthopaedic physical therapy practice. A standardized yellow flag assessment tool will better inform treatment decision making related to psychologically informed practice. Objectives To describe the development of a concise, multidimensional yellow flag assessment tool for application in orthopaedic physical therapy clinical practice. Methods A 136-item yellow flag item bank was developed from validated psychological questionnaires across domains related to pain vulnerability (negative mood, fear avoidance) and resilience (positive affect/coping). Patients seeking physical therapy with neck, back, knee, or shoulder pain completed the item bank. Iterative statistical analyses determined minimal item sets meeting thresholds for identifying elevated vulnerability or low resilience (ie, upper or lower quartile, as indicated). Further item reduction yielded a concise yellow flag assessment tool to assess 11 psychological constructs measuring pain-associated psychological distress. Correlations between the assessment tool and individual psychological questionnaires were measured and compared between anatomical regions. Concurrent validity was assessed by determining variance explained in pain and disability scores by the assessment tool. Results Subjects with elevated vulnerability and decreased resilience were identified with a high degree of accuracy (minimum of 85%) using a 17-item tool. Correlations were moderate to high between the 17-item tool and individual psychological questionnaires, with no significant differences in correlations between different anatomical regions. Shorter 10- and 7-item versions of the assessment tool allow clinicians the flexibility to assess for yellow flags quickly with acceptable trade-offs in accuracy (81% and 75%, respectively). All versions of the tool explained significant additional variance in pain and disability scores (range, 19.3%-36.7%) after accounting for demographics, historical variables, and anatomical region of pain. Conclusion Concise assessment of yellow flags is feasible in outpatient physical therapy settings. This multidimensional tool advances assessment of pain-associated psychological distress through the addition of positive affect/coping constructs and estimation of full questionnaire scores. Further study is warranted to determine how this tool complements established risk-assessment tools by providing the option for efficient treatment monitoring. J Orthop Sports Phys Ther 2016;46(5):327-345. Epub 21 Mar 2016. doi:10.2519/jospt.2016.6487.

Generalization of socially transmitted and instructed avoidance

Excessive avoidance behavior, in which an instrumental action prevents an upcoming aversive event, is a defining feature of anxiety disorders. Left unchecked, both fear and avoidance of potentially threatening stimuli may generalize to perceptually related stimuli and situations. The behavioral consequences of generalization mean that aversive learning experiences with specific threats may lead to the inference that classes of related stimuli are threatening, potentially dangerous, and need to be avoided, despite differences in physical form. Little is known however about avoidance generalization in humans and the learning pathways by which it may be transmitted. In the present study, we compared two pathways to avoidance—instructions and social observation—on subsequent generalization of avoidance behavior, fear expectancy and physiological arousal. Participants first learned that one cue was a danger cue (conditioned stimulus, CS+) and another was a safety cue (CS−). Groups were then either instructed that a simple avoidance response in the presence of the CS+ cancelled upcoming shock (instructed-learning group) or observed a short movie showing a demonstrator performing the avoidance response to prevent shock (observational-learning group). During generalization testing, danger and safety cues were presented along with generalization stimuli that parametrically varied in perceptual similarity to the CS+. Reinstatement of fear and avoidance was also tested. Findings demonstrate, for the first time, generalization of socially transmitted and instructed avoidance: both groups showed comparable generalization gradients in fear expectancy, avoidance behavior and arousal. Return of fear was evident, suggesting that generalized avoidance remains persistent following extinction testing. The utility of the present paradigm for research on avoidance generalization is discussed.