Pain demands attention from others: the approach/avoidance paradox

The closer you feel, the more you care: Positive associations between closeness, pain intensity rating, empathic concern and personal distress to someone in pain

Previous research revealed inconsistent findings regarding affective responses when facing someone in pain (i.e., empathic concern and/or personal distress). In this paper, we suggest that the degree of closeness between the observer and the person in pain may account for these contradictory results, such that greater closeness towards this person leads to higher personal distress. To test this hypothesis, we induced either low or high closeness with a confederate in 69 randomly assigned participants. Following the closeness induction, participants evaluated their affective responses (empathic concern and personal distress) and rated the confederate's pain intensity after watching the confederate undergoing a painful cold pressure task. Results showed that, despite the non-significant effect of closeness induction, closeness across both conditions (low and high) was positively correlated with pain intensity rating, empathic concern and personal distress. This study thus suggests that closeness is associated with higher cognitive and affective responses to a person in pain.

Interpretation biases and visual attention in the processing of ambiguous information in chronic pain

BACKGROUND

Theories propose that interpretation biases and attentional biases might account for the maintenance of chronic pain symptoms, but the interactions between these two forms of biases in the context of chronic pain are understudied.

METHODS

To fill this gap, 63 participants (40 females) with and without chronic pain completed an interpretation bias task that measures participants' interpretation styles in ambiguous scenarios and a novel eye-tracking task where participants freely viewed neutral faces that were given ambiguous pain/health-related labels (i.e. 'doctor', 'patient' and 'healthy people'). Eye movements were analysed with the Hidden Markov Models (EMHMM) approach, a machine-learning data-driven method that clusters people's eye movements into different strategy subgroups.

RESULTS

Adults with chronic pain endorsed more negative interpretations for scenarios related to immediate bodily injury and long-term illness than healthy controls, but they did not differ significantly in terms of their eye movements on ambiguous faces. Across groups, people who interpreted illness-related scenarios in a more negative way also focused more on the nose region and less on the eye region when looking at patients' and healthy people's faces and, to a lesser extent, doctors' faces. This association between interpretive and attentional processing was particularly apparent in participants with chronic pain.

CONCLUSIONS

In summary, the present study provided evidence for the interplay between multiple forms of cognitive biases. Future studies should investigate whether this interaction might influence subsequent functioning in people with chronic pain.

Perspective-taking influences attentional deployment towards facial expressions of pain: an eye-tracking study

Empathetic perspective-taking (PT) may be critical in modulating attention and associated responses to another's pain. However, the differential effects of imagining oneself to be in the pain sufferer's situation ("Self-perspective") or imagining the negative impacts on the pain sufferer's experience ("Other-perspective") on attention have not been studied. The effects of observer PT (Self vs Other) and level of facial pain expressiveness (FPE) upon attention to another person's pain was investigated. Fifty-two adults were assigned to 1 of 3 PT conditions; they were instructed to view pairs of pain expressions and neutral faces and either (1) consider their own feelings (Self-perspective), (2) consider the feelings of the person in the picture (Other-perspective), or (3) received no further instructions (Control). Eye movements provided indices of early (probability and duration of first fixation) and later (total gaze duration) attentional deployment. Pain faces were more likely to be fixated upon first. A significant first fixation duration bias towards pain was observed, which increased with increasing levels of FPE, and was higher in the Self-PT than the Control condition. The proportion of total gaze duration on pain faces was higher in both experimental conditions than the Control condition. This effect was moderated by FPE in the Self-PT condition; there was a significant increase from low to high FPE. When observers attend to another's facial display of pain, top-down influences (such as PT) and bottom-up influences (such as sufferer's FPE) interact to control deployment and maintenance of attention.

Physical Cue Influences Children's Empathy for Pain: The Role of Attention Allocation

Empathy for pain is evolutionally important and context-dependent. The current study explored the effect of physical cue on 4- to 5-year-old children’s empathy for pain with two experiments. Experiment 1 investigated the effect of valid and invalid physical cue as compared to baseline (without cue) in pain evaluation task (evaluating the pain intensity of a facial expression, N = 28). Experiment 2 employed eye-tracking to investigate the attentional process in valid and baseline conditions (evaluating the pain intensity of a body image with an apparently injured arm or leg, N = 65). We found the evaluation of pain intensity was the highest in the valid condition, and higher in baseline condition than invalid. As for eye-tracking results, children fixated more quickly, had more fixations and longer total fixation duration in valid-cue condition. Of attention allocation, compared with baseline condition, children fixated on arm/leg more quickly, more frequently and for longer time in valid condition. Additionally, eye-tracking results were significantly related to their evaluation of pain intensity.

Circles of engagement: Childhood pain and parent brain

Social interaction can have a profound effect on individual behavior, perhaps most salient in interactions between sick suffering children and their parents. Chronic pain is a difficult condition that can produce considerable changes in children's behaviors that can secondarily have profound effects on their parents. It may create a functionally disabling negative feedback loop. Research supports the notion of alterations in the brain of individuals who observe and empathize with loved ones in acute pain. However, neural activity in relation to empathic responses in the context of chronic pain has not been examined. Ongoing suffering with chronic pain in a child can result in child's brain circuit alterations. Moreover, prolonged suffering jointly experienced by the parent may putatively produce maladaptive changes in their neural networks and consequently in parental behaviors. Here we put forth the conceptual framework for 'Chronic pain contagion' (CPC). We review the underlying processes in CPC and discuss implications for devising and implementing treatments for children in chronic pain and their parents.

Caregivers' attentional bias to pain: does it affect caregiver accuracy in detecting patient pain behaviors?

Attentional bias to pain among family caregivers of patients with pain may enhance the detection of pain behaviors in patients. However, both relatively high and low levels of attentional bias may increase disagreement between patients and caregivers in reporting pain behaviors. This study aims to provide further evidence for the presence of attentional bias to pain among family caregivers, to examine the association between caregivers' attentional bias to pain and detecting pain behaviors, and test whether caregivers' attentional bias to pain is curvilinearly related to patient and caregiver disagreement in reporting pain behaviors. The sample consisted of 96 caregivers, 94 patients with chronic pain, and 42 control participants. Caregivers and controls completed a dot-probe task assessing attention to painful and happy stimuli. Both patients and caregivers completed a checklist assessing patients' pain behavior. Although caregivers did not respond faster to pain congruent than pain incongruent trials, caregiver responses were slower in pain incongruent trials compared with happy incongruent trials. Caregivers showed more bias toward pain faces than happy faces, whereas control participants showed more bias toward happy faces than pain faces. Importantly, caregivers' attentional bias to pain was significantly positively associated with reporting pain behaviors in patients above and beyond pain severity. It is reassuring that attentional bias to pain was not related to disagreement between patients and caregivers in reporting pain behaviors. In other words, attentional bias does not seem to cause overestimation of pain signals.

Pain and empathy: the effect of self-oriented feelings on the detection of painful facial expressions

BACKGROUND

Painful facial expressions have been shown to trigger affective responses among observers. However, there is so far no clear indication about the self- or other-oriented nature of these feelings. The purpose of this study was to assess whether facial expressions of pain are unconsciously associated with other-oriented feelings (empathic concern) or with self-oriented feelings (personal distress).

METHOD

70 participants took part in a priming paradigm in which ambiguous facial expressions of pain were primed by words related to empathic concern, distress, negative or by neutral words. It was hypothesized that empathic concern or distress-related words might facilitate the detection of pain in ambiguous facial expressions of pain, independently of a mere effect of prime (i.e., neutral words) or an effect of valence congruency (negative primes).

RESULTS

The results showed an effect of prime on the detection and on the reaction time to answer "pain" when confronted to ambiguous facial expressions of pain. More specifically, the detection of pain was higher and faster when preceded by distress primes relative to either neutral or negative primes.

CONCLUSION

The present study suggests that painful expressions are unconsciously related to self-oriented feelings of distress and that their threat value might account for this effect. These findings thus shed new light on the automatic relationship between painful expressions and the affective components of empathy.

Developmental and individual differences in the neural processing of dynamic expressions of pain and anger

We examined the processing of facial expressions of pain and anger in 8-month-old infants and adults by measuring event-related brain potentials (ERPs) and frontal EEG alpha asymmetry. The ERP results revealed that while adults showed a late positive potential (LPP) to emotional expressions that was enhanced to pain expressions, reflecting increased evaluation and emotional arousal to pain expressions, infants showed a negative component (Nc) to emotional expressions that was enhanced to angry expressions, reflecting increased allocation of attention to angry faces. Moreover, infants and adults showed opposite patterns in their frontal asymmetry responses to pain and anger, suggesting developmental differences in the motivational processes engendered by these facial expressions. These findings are discussed in the light of associated individual differences in infant temperament and adult dispositional empathy.

Vicarious pain while observing another in pain: an experimental approach

Objective: This study aimed at developing an experimental paradigm to assess vicarious pain experiences. We further explored the putative moderating role of observer's characteristics such as hypervigilance for pain and dispositional empathy.

Methods: Two experiments are reported using a similar procedure. Undergraduate students were selected based upon whether they reported vicarious pain in daily life, and categorized into a pain responder group or a comparison group. Participants were presented a series of videos showing hands being pricked whilst receiving occasionally pricking (electrocutaneous) stimuli themselves. In congruent trials, pricking and visual stimuli were applied to the same spatial location. In incongruent trials, pricking and visual stimuli were in the opposite spatial location. Participants were required to report on which location they felt a pricking sensation. Of primary interest was the effect of viewing another in pain upon vicarious pain errors, i.e., the number of trials in which an illusionary sensation was reported. Furthermore, we explored the effect of individual differences in hypervigilance to pain, dispositional empathy and the rubber hand illusion (RHI) upon vicarious pain errors.

Results: Results of both experiments indicated that the number of vicarious pain errors was overall low. In line with expectations, the number of vicarious pain errors was higher in the pain responder group than in the comparison group. Self-reported hypervigilance for pain lowered the probability of reporting vicarious pain errors in the pain responder group, but dispositional empathy and the RHI did not.

Conclusion: Our paradigm allows measuring vicarious pain experiences in students. However, the prevalence of vicarious experiences of pain is low, and only a small percentage of participants display the phenomenon. It remains however unknown which variables affect its occurrence.

Pediatric fear-avoidance model of chronic pain: foundation, application and future directions

The fear-avoidance model of chronic musculoskeletal pain has become an increasingly popular conceptualization of the processes and mechanisms through which acute pain can become chronic. Despite rapidly growing interest and research regarding the influence of fear-avoidance constructs on pain-related disability in children and adolescents, there have been no amendments to the model to account for unique aspects of pediatric chronic pain. A comprehensive understanding of the role of fear-avoidance in pediatric chronic pain necessitates understanding of both child⁄adolescent and parent factors implicated in its development and maintenance. The primary purpose of the present article is to propose an empirically-based pediatric fear-avoidance model of chronic pain that accounts for both child⁄adolescent and parent factors as well as their potential interactive effects. To accomplish this goal, the present article will define important fear-avoidance constructs, provide a summary of the general fear-avoidance model and review the growing empirical literature regarding the role of fear-avoidance constructs in pediatric chronic pain. Assessment and treatment options for children with chronic pain will also be described in the context of the proposed pediatric fear-avoidance model of chronic pain. Finally, avenues for future investigation will be proposed.

Dispositional empathy modulates vicarious effects of dynamic pain expressions on spinal nociception, facial responses and acute pain

Pain communication is thought to promote automatic vicarious self-protective responses as well as empathic concern towards others' suffering. This duality was recently highlighted in a study showing that highly empathic individuals display increased vicarious facilitation of low-level pain processing (nociceptive flexion reflex, NFR) combined with an unexpected reduced facilitation of self-pain perception (pain ratings) while viewing static pictures evoking pain in others. The present study sought to test further the moderating effects of dispositional empathy on vicarious responses induced by viewing dynamic pain expressions. Twenty-four healthy volunteers viewed 1-s videos showing different levels of pain expression before noxious electric shocks were delivered to the sural nerve. Viewing stronger pain expressions generally increased shock-pain unpleasantness ratings, the amplitude of the NFR, and facial responses (corrugator muscle) to the noxious stimulation. However, self-pain ratings (intensity and unpleasantness) increased less or were reduced following clips of pain expression in individuals scoring higher on the Empathy Quotient. These results suggest that vicarious processes facilitate low-level defensive responses, while the experience of self-pain and the associated negative affect may be partly tuned-down by higher-order empathic processes.

The impact of parental gender, catastrophizing and situational threat upon parental behaviour to child pain: a vignette study

BACKGROUND

This study examined which parents report to be solicitous or discouraging in response to their child's pain, and when they do so.

METHODS

Using a vignette methodology, mothers (n = 472) and fathers (n = 271) imagined their child in pain situations varying in duration (1 day or several weeks) and cause of pain (known or unknown biomedical cause).

RESULTS

In general, fathers demonstrated similar tendencies toward solicitousness than mothers, but reported to engage more in discouraging behaviours. In line with expectations, parents who catastrophized about their child's pain reported a higher inclination to engage in solicitous behaviours. Only for fathers, high catastrophizing was also related to a higher report of discouraging behaviours. However, the effects of catastrophizing differed across situations varying in duration and cause of pain. Specifically, the effect of parental catastrophizing upon self-reported solicitous behaviours was particularly strong when imagining their child in pain with unknown biomedical cause. Further, high catastrophizing in fathers only translated in a higher inclination for discouraging responses when imagining their child in pain of short duration.

CONCLUSIONS

The findings of the current study highlight the importance of parental catastrophizing in explaining parental behavioural tendencies in response to their child in pain. Further, reported behaviours were found to vary across pain situations, attesting to the importance of studying parental behaviour 'in context'.

Impact of parental catastrophizing and contextual threat on parents' emotional and behavioral responses to their child's pain

Limited research has addressed processes underlying parents' empathic responses to their child's pain. The present study investigated the effects of parental catastrophizing, threatening information about the child's pain, and child pain expression upon parental emotional and behavioral responses to their child's pain. A total of 56 school children participated in a heat pain task consisting of 48 trials while being observed by 1 of their parents. Trials were preceded by a blue or yellow circle, signaling possible pain stimulation (i.e., pain signal) or no pain stimulation (i.e., safety signal). Parents received either neutral or threatening information regarding the heat stimulus. Parents' negative emotional responses when anticipating their child's pain were assessed using psychophysiological measures- i.e., fear-potentiated startle and corrugator EMG activity. Parental behavioral response to their child's pain (i.e., pain attending talk) was assessed during a 3-minute parent-child interaction that followed the pain task. The Child Facial Coding System (CFCS) was used to assess children's facial pain expression during the pain task. Results indicated that receiving threatening information was associated with a stronger parental corrugator EMG activity during pain signals in comparison with safety signals. The same pattern was found for parental fear-potentiated startle reflex, particularly when the child's facial pain expression was high. In addition, parents who reported high levels of catastrophizing thought about their child's pain engaged, in comparison with low-catastrophizing parents, in more pain-attending talk when they received threatening information. The findings are discussed in the context of affective-motivational theories of pain.

Perceiving pain in others: automatic and controlled mechanisms

Recent developments in clinical, cognitive, and behavioral sciences as well as in social neuroscience can provide new perspectives on our understanding of different forms of pain expression and the social reactions of observers to various types of pain expression. Studies indicate that pain expression is governed by both automatic (unintentional, reflexive) and controlled (intentional, purposive) neuroregulatory systems. Reciprocal mechanisms in observers responsible for automatic (unintentional, reflexive) and controlled (intentional, reflective) reactions also are important. Observers appear more likely to display immediate "visceral" emotional reactions to unintentional, reflexive expression, whereas controlled expression characterized by purposive behavior appears more likely to elicit reflection on the nature and origins of the person's pain. This review summarizes research within the context of a theoretical model for understanding how pain is perceived in others.

PERSPECTIVE

People attempting to understand another person's pain may have access to the person's spontaneous behavioral reaction as well as verbal report and other purposive communications. The former instigates reflexive and emotional reactions, whereas the latter tends to be perceived as confounding expression of experience with response to situational demands.