Attentional, interpretation and memory biases for sensory-pain words in individuals with chronic headache

The Interrelationships Between Cognitive Biases for Pain: An Experimental Study

Contemporary pain models highlight cognitive-processing biases (ie, attention bias [AB], interpretation bias [IB], and memory bias [MB]) as key processes that contribute to poor pain outcomes. However, existing research has yielded inconsistent findings regarding the presence and impact of these biases on pain outcomes. Recognizing the need to explore these biases simultaneously, contemporary pain models suggest that cognitive biases (CBs) are interrelated, and may have a combined impact upon pain problems. The current study aims to investigate the interrelationships between CBs using the PainAIM paradigm, a novel approach enabling simultaneous evaluation of pain-related AB, IB, and MB using cues signaling actual pain rather than symbolic information. We hypothesized the presence and positive associations of biases for pain-related cues and the predictive value of combined AB and IB for poor pain outcomes. Eighty-four healthy participants completed the PainAIM paradigm, followed by a cold pressor task probing pain experience and pain-related task interference. The results indicated an inverse relationship between AB and IB for ambiguous pain cues. In addition, there was a positive association between participants' AB for ambiguous pain and their MB for the same cues. Contrary to our hypotheses, CB indices did not predict experimental pain outcomes. These findings provide support for the interrelationships between pain-related CBs. However, future research on the temporal order of CBs and their combined impact on pain outcomes is needed. By overcoming the limitations associated with traditional paradigms, the PainAIM paradigm offers a promising research tool for the further study of combined CBs in the context of pain. PERSPECTIVE: The current study provides insight into the associations between pain-related CBs (AB, IB, and MB) using ecologically valid (ambiguous) pain cues. The results indicated an inverse association between pain-related AB and IB, while a positive association was found between AB and MB. CBs did however not predict experimental pain outcomes.

Interpretation bias in endometriosis-related pain

ABSTRACT

Endometriosis-related pain has been predominantly medically managed, which has hindered understanding of psychological factors involved in these pain experiences. Models of chronic pain highlight the biased interpretation of ambiguous information as health threat related (interpretation bias) as an important process in the development and maintenance of chronic pain. Whether interpretation bias may also be similarly implicated in endometriosis-related pain is unclear. The current study aimed to address this gap in the literature by (1) comparing interpretation biases between a sample of participants with endometriosis and a control sample of participants without medical conditions and pain, (2) exploring relationships between interpretation bias and endometriosis-related pain outcomes, and (3) exploring whether interpretation bias moderated the relationship between endometriosis-related pain severity and pain interference. The endometriosis and healthy control samples comprised 873 and 197 participants, respectively. Participants completed online surveys assessing demographics, interpretation bias, and pain-related outcomes. Analyses revealed that interpretation bias was significantly stronger among individuals with endometriosis relative to controls, with a large effect size. Within the endometriosis sample, interpretation bias was significantly associated with increases in pain-related interference, however, interpretation bias was not associated with any other pain outcomes and did not moderate the relationship between pain severity and pain interference. This study is the first to evidence biased interpretation styles among individuals with endometriosis and to show this bias is associated with pain interference. Whether interpretation bias varies over time and whether this bias can be modified through scalable and accessible interventions to alleviate pain-related interference are avenues for future research.

The Role of Pain Catastrophizing, Emotional Intelligence, and Pain Intensity in the Quality of Life of Cancer Patients with Chronic Pain

Pain catastrophizing (PC) is a negative cognitive distortion to actual or anticipated pain. This study aims to investigate the relationship between pain catastrophizing, emotional intelligence, pain intensity, and quality of life (QoL) in cancer patients with chronic pain. Eighty-nine outpatients with chronic pain attending pain clinics and palliative care units were recruited. Participants were men (42.7%) and women (57.3%) with an average age of 56.44 years (SD = 14.82). Self-report psychological measures were completed, including a measure of emotional intelligence, a standard measure of PC, a scale assessing pain intensity, and a scale measuring QoL. The PC scale was found to assess three correlated yet different dimensions of pain catastrophizing (helplessness, magnification, and rumination). Moreover, as expected, patients with PC scale scores ≥ 30 had lower scores in functional QoL dimensions and higher scores in the fatigue, pain, and insomnia symptom dimensions. Regression analyses demonstrated that PC (B = − 0.391, p = 0.004), pain intensity (B = − 1.133, p < 0.001), and education (B = 2.915, p = 0.017) remained the only significant variables related to QoL, when controlling for demographic and clinical confounders. Regarding mediating effects, PC and pain intensity were jointly found to be significant mediators in the relationship between emotional intelligence and QoL. Results are discussed in the context of the clinical implications regarding interventions designed to improve cancer patients’ quality of life and offer new insight, understanding, and evaluation targets in the field of pain management.

Testing a Combined Cognitive Bias Hypothesis of Pain and Pain-related Worry in Young People

Cognitive factors are thought to contribute and maintain pain experiences in young people. However, most of these factors have been assessed in isolation. Considering more than 1 cognitive factor could increase explanatory power and identify multiple targets for intervention. Here, we tested a Combined Cognitive Bias Hypothesis (CCBH) that suggests information-processing factors associate with each other and exert either additive and/or interactive influences on pain outcomes. We conducted secondary analysis of data from 243 adolescents aged 16 to 19 years, who had completed a task measuring pain-related attention control impairments (emotion-priming visual search task) and a task measuring biased interpretations towards threatening cues (Adolescent Interpretation of Bodily Threat task). These young people also completed measures of recent pain experiences and pain catastrophizing, which served as primary and secondary outcomes, respectively. Regression analyses revealed that difficulties with attention control (following presentation of pain-related stimuli) and tendencies to endorse threatening interpretations of ambiguous situations had significant additive effects on both pain outcomes. However, correlations between these factors were non-significant. They also did not interact to influence pain outcomes. These findings require replication in broader age ranges and clinical samples but potentially suggest that, measuring multiple cognitive factors increases explanatory power of youth pain outcomes. PERSPECTIVE: Weak attention control following exposure to pain cues and tendencies to endorse threat interpretations, uniquely and additively associate with self-reported pain experiences and pain catastrophizing in community youth. Measuring several cognitive factors simultaneously could improve our ability to explain pain outcomes in adolescent populations.

Association between attentional bias to experimentally induced pain and to pain-related words in healthy individuals: the moderating role of interpretation bias

ABSTRACT

Attentional bias to pain-related information may contribute to chronic pain maintenance. It is theoretically predicted that attentional bias to pain-related language derives from attentional bias to painful sensations; however, the complex interconnection between these types of attentional bias has not yet been tested. This study aimed to investigate the association between attentional bias to pain words and attentional bias to the location of pain, as well as the moderating role of pain-related interpretation bias in this association. Fifty-four healthy individuals performed a visual probe task with pain-related and neutral words, during which eye movements were tracked. In a subset of trials, participants were presented with a cold pain stimulus on one hand. Pain-related interpretation and memory biases were also assessed. Attentional bias to pain words and attentional bias to the pain location were not significantly correlated, although the association was significantly moderated by interpretation bias. A combination of pain-related interpretation bias and attentional bias to painful sensations was associated with avoidance of pain words. In addition, first fixation durations on pain words were longer when the pain word and cold pain stimulus were presented on the same side of the body, as compared to on opposite sides. This indicates that congruency between the locations of pain and pain-related information may strengthen attentional bias. Overall, these findings indicate that cognitive biases to pain-related information interact with cognitive biases to somatosensory information. The implications of these findings for attentional bias modification interventions are discussed.

Interpretation Biases in Pain: Validation of Two New Stimulus Sets

Adults with chronic pain interpret ambiguous information in a pain and illness related fashion. However, limitations have been highlighted with traditional experimental paradigms used to measure interpretation biases. Whilst ambiguous scenarios have been developed to measure interpretation biases in adolescents with pain, no scenario sets exist for use with adults. Therefore, the present study: (i) sought to validate a range of ambiguous scenarios suitable for measuring interpretation biases in adults, whilst also allowing for two response formats (forced-choice and free response); and (ii) investigate paradigm efficacy, by assessing the effects of recent pain experiences on task responding. A novel ambiguous scenarios task was administered to adults (N = 241). Participants were presented with 62 ambiguous scenarios comprising 42 that could be interpreted in a pain/pain-illness or non-pain/non-pain illness manner: and 20 control scenarios. Participants generated their own solutions to each scenario (Word Generation Task), then rated how likely they would be to use two researcher-generated solutions to complete each scenario (Likelihood Ratings Task). Participants also rated their subjective experiences of pain in the last 3 months. Tests of reliability, including inter-rater agreement and internal consistency, produced two ambiguous scenario stimulus sets containing 18 and 20 scenarios, respectively. Further analyses revealed adults who reported more recent pain experiences were more likely to endorse the pain/pain-illness solutions in the Likelihood Ratings Task. This study provides two new stimulus sets for use with adults (including control items) in pain research and/or interventions. Results also provide evidence for a negative endorsement bias in adults.

The effects of attentional and interpretation biases on later pain outcomes among younger and older adults: A prospective study

BACKGROUND

Studies examining the effect of biased cognitions on later pain outcomes have primarily focused on attentional biases, leaving the role of interpretation biases largely unexplored. Also, few studies have examined pain-related cognitive biases in elderly persons. The current study aims to fill these research gaps.

METHODS

Younger and older adults with and without chronic pain (N = 126) completed an interpretation bias task and a free-viewing task of injury and neutral scenes at baseline. Participants' pain intensity and disability were assessed at baseline and at a 6-month follow-up. A machine-learning data-driven approach to analysing eye movement data was adopted.

RESULTS

Eye movement analyses revealed two common attentional pattern subgroups for scene-viewing: an "explorative" group and a "focused" group. At baseline, participants with chronic pain endorsed more injury-/illness-related interpretations compared to pain-free controls, but they did not differ in eye movements on scene images. Older adults interpreted illness-related scenarios more negatively compared to younger adults, but there was also no difference in eye movements between age groups. Moreover, negative interpretation biases were associated with baseline but not follow-up pain disability, whereas a focused gaze tendency for injury scenes was associated with follow-up but not baseline pain disability. Additionally, there was an indirect effect of interpretation biases on pain disability 6 months later through attentional bias for pain-related images.

CONCLUSIONS

The present study provided evidence for pain status and age group differences in injury-/illness-related interpretation biases. Results also revealed distinct roles of interpretation and attentional biases in pain chronicity.

SIGNIFICANCE

Adults with chronic pain endorsed more injury-/illness-related interpretations than pain-free controls. Older adults endorsed more illness interpretations than younger adults. A more negative interpretation bias indirectly predicted pain disability 6 months later through hypervigilance towards pain.

Examining attentional biases, interpretation biases, and attentional control in people with and without chronic pain

ABSTRACT

Psychological models of chronic pain (CP) highlight cognitive-processing biases (ie, attentional biases, interpretation biases, and attentional control) as pivotal processes that uniquely and synergistically impact the development and maintenance of CP. Very few studies explore multiple cognitive biases, and no studies have examined these 3 processes together in a CP sample. Furthermore, there is a lack of research investigating the relationship between these cognitive processes and pain-relevant variables (eg, pain intensity and pain catastrophising). The current study aimed to (1) compare attentional biases, interpretation biases, and attentional control in people with and without CP, (2) explore their interrelationships, and (3) explore their association with pain-related variables. Seventy-four participants with CP and 66 without pain volunteered. Participants completed a visual scanning task with eye tracking, a recognition task, and a flanker task. Traditional and Bayesian analysis indicated no effect of pain status on cognitive-processing biases. All participants, regardless of pain status, demonstrated attentional biases towards pain on some indices of early and late attention, but not interpretation bias or attentional control. There was weak evidence of associations between attentional biases, interpretation biases, and attentional control. Pain intensity was significantly correlated with interpretation biases, and follow-up analyses revealed people with high pain intensity demonstrated an interpretation bias towards pain significantly more than those with low pain intensity. Findings suggest that attentional biases towards pain are ubiquitous, but for people with moderate-to-severe pain, interpretation biases may have a role worthy of further research.

Attentional bias to somatosensory stimuli in chronic pain patients: a systematic review and meta-analysis

ABSTRACT

This systematic review and meta-analysis aimed to evaluate the evidence pertaining to attentional bias for painful and nonpainful somatosensory stimuli in individuals with chronic pain. Eligible studies were identified through searches of Medline, PsycINFO, CINAHL, Web of Science, Scopus, and Cochrane Library databases. Search terms were words and phrases organised into 3 concept blocks: pain condition, cognitive process, and stimuli/paradigm. The search identified 29 eligible studies (reporting 32 eligible experiments), of which quantitative meta-analysis was possible for 16 studies (19 experiments). The meta-analysis found that chronic pain patients, excluding somatoform pain patients, showed significantly greater attentional bias to stimuli in the somatosensory modality than healthy controls (k = 9, g = 0.34). In addition, meta-analysis of studies that used a temporal order judgement task found that patients with unilateral chronic pain showed a spatial attentional bias away from somatosensory stimuli (k = 7, effect estimate = 22.43 ms) and visual stimuli (k = 2, effect estimate = 13.75 ms) on or near the painful body side. Most studies of attentional bias to the somatosensory modality recruited samples of patients with fibromyalgia, whereas most studies of spatial attentional bias assessed patients with complex regional pain syndrome. The extent to which these results generalise to other pain conditions is therefore unclear. We recommend future research test spatial and modality attentional biases across chronic pain conditions and examine the psychometric properties of attentional bias measurement paradigms for use with chronic pain populations. PROSPERO registration number CRD42019124510.

Attentional Patterns Toward Pain-Related Information: Comparison Between Chronic Pain Patients and Non-pain Control Group

Although the evidence for attentional bias to pain-related information among individuals with chronic pain has been well established, there are a number of inconsistencies in the research that have been observed due to sample characteristics. Therefore, the present study expanded upon previous studies by including patients with a variety of chronic pain conditions and compared a chronic pain patient sample with healthy community sample. We also investigated how pain catastrophizing and other psychological factors in chronic pain patients affected attentional patterns to pain-related information. Forty chronic pain patients from the departments of neurology and rheumatology of an academic medical center hospital and 40 participants without chronic pain from a university that is located in Seoul, South Korea were recruited for the present study. Patients observed pictures of faces displaying pain that were presented simultaneously with faces with neutral expressions, while their eye movements were measured using an eye-tracking system. Independent t-tests were conducted to investigate attentional preferences to pain stimuli between the chronic pain and control groups. No significant attentional differences in pain-neutral pairs were found for both chronic pain and control group. A one-way MANOVA was conducted to examine the role of pain catastrophizing on psychological factors and attentional engagement to pain stimuli. No significant results for the attentional bias to pain stimuli among chronic pain patients may indicate that chronic pain patients who have suffered from chronic pain for a long time and have been treated for their chronic pain in the hospital may interpret pain-related information not as threatening. Clinical implications related to use in pain treatment and future research suggestions are discussed.

A systematic review with subset meta-analysis of studies exploring memory recall biases for pain-related information in adults with chronic pain

Supplemental Digital Content is Available in the Text.

Pain-related memory biases have been frequently explored in individuals with chronic pain, and along with attentional and interpretation biases are hypothesised to contribute to the onset and/or maintenance of chronic pain. The aim of this review is to provide a systematic review and synthesis of studies exploring memory recall biases for pain-related information in individuals with chronic pain relative to healthy controls and the recall of neutral information. Studies were identified through a search of Medline, PsychINFO, Web of Science, CINAHL, Cochrane Library, and Open Grey databases. Search terms were memory, recall, recognition, and bias*, intersected with pain. Eighteen studies meeting the inclusion criteria were included. Subset meta-analyses are also reported from 12 studies with relevant between-groups data (comparing recall in chronic pain vs healthy control groups) and 12 studies with relevant within-groups data (eg, comparing recall of pain-related/emotional vs neutral words). Between-groups analysis revealed significantly weaker recall bias for affective-pain words in individuals with chronic pain relative to healthy controls, but only when nondepressed chronic pain individuals were included. No significant differences were found between groups in the recall of sensory-pain, illness-related, or depression-related words. Within-groups analysis revealed individuals with chronic pain show a significant recall bias favouring sensory-pain words relative to neutral and affective-pain words, and a bias for illness-related words relative to depression-related words. A recall bias favouring neutral words was found in healthy individuals. Evidence for the presence of pain-related memory biases in patients with chronic pain is inconclusive. Further methodologically rigorous research is required.

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.

How Perceptions Impact Recovery from Concussion in Childhood and Adolescence: a Systematic Review

Perceptions about the causes and consequences of concussion, and individual representations and interpretations of these factors, can influence the post-concussive recovery process. The goal of this project was to synthesize evidence on perceptions related to concussions as experienced by children, adolescents, and parents, and to evaluate how these perceptions impact post-concussive recovery in physical, behavioural, cognitive, and psychological domains. We undertook a systematic review based on the Cochrane Handbook, conducting a comprehensive search of six databases and Google Scholar. Duplicate, independent screening was employed and the quality of studies was assessed using the Mixed Methods Appraisal Tool (MMAT). A total of 1552 unique records were identified, and six records (5 scientific articles and 1 thesis, published between 1990 and 2018; N = 26 to 412, age range from 2 to 18 years) were included. Perceptions about concussions were assessed differently between studies, with a range in types of measures and respondents. Some evidence suggested that perceptions could negatively impact concussion recovery, mostly post-concussive symptoms. However, results were not consistent between studies and the methodological quality was variable (and often low). There is limited evidence of the impact of perceptions of children, adolescents, and their parents on concussion recovery. Priorities for future research investigating concussion recovery should include recruiting representative samples, accounting for potential confounders, and measuring perceptions in children, adolescents and parents using validated measures. Higher quality studies are needed to better understand the role of perceptions in concussion recovery and to inform clinical care.

Internet-delivered attentional bias modification training (iABMT) for the management of chronic musculoskeletal pain: a protocol for a randomised controlled trial

INTRODUCTION

Chronic musculoskeletal pain is a complex medical condition that can significantly impact quality of life. Patients with chronic pain demonstrate attentional biases towards pain-related information. The therapeutic benefits of modifying attentional biases by implicitly training attention away from pain-related information towards neutral information have been supported in a small number of published studies. Limited research however has explored the efficacy of modifying pain-related biases via the internet. This protocol describes a randomised, double-blind, internet-delivered attentional bias modification intervention, aimed to evaluate the efficacy of the intervention on reducing pain interference. Secondary outcomes are pain intensity, state and trait anxiety, depression, pain-related fear, and sleep impairment. This study will also explore the effects of training intensity on these outcomes, along with participants' perceptions about the therapy.

METHODS AND ANALYSIS

The study is a double-blind, randomised controlled trial with four arms exploring the efficacy of online attentional bias modification training versus placebo training theorised to offer no specific therapeutic benefit. Participants with chronic musculoskeletal pain will be randomised to one of four groups: (1) 10-session attentional modification group; (2) 10-session placebo training group; (3) 18-session attentional modification group; or (4) 18-session placebo training group. In the attentional modification groups, the probe-classification version of the visual-probe task will be used to implicitly train attention away from threatening information towards neutral information. Following the intervention, participants will complete a short interview exploring their perceptions about the online training. In addition, a subgroup analysis for participants aged 16-24 and 25-60 will be undertaken.

ETHICS AND DISSEMINATION

This study has been approved by the University of Southampton Research Ethics Committee. Results will be published in peer-reviewed journals, academic conferences, and in lay reports for pain charities and patient support groups.

TRIAL REGISTRATION NUMBER

NCT02232100; Pre-results.