The social modulation of pain: others as predictive signals of salience - a systematic review

Educational needs and preferences of adult patients with acute pain: a mixed-methods systematic review

ABSTRACT

Many patients experience acute pain, which has been associated with numerous negative consequences. Pain education has been proposed as a strategy to improve acute pain management. However, studies report limited effects with educational interventions for acute pain in adults, which can be explained by the underuse of the person-centered approach. Thus, we aimed to systematically review and synthetize current evidence from quantitative, qualitative and mixed-methods studies describing patients' needs and preferences for acute pain education in adults. We searched original studies and gray literature in 7 databases, from January 1990 to October 2023. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A total of 32 studies were included (n = 1847 patients), two-thirds of which were qualitative studies of high methodological quality. Most of the studies were conducted over the last 15 years in patients with postsurgical and posttraumatic pain, identified as White, with a low level of education. Patients expressed the greatest need for education when it came to what to expect in pain intensity and duration, as well how to take the medication and its associated adverse effects. The most frequently reported educational preferences were for in-person education while involving caregivers and to obtain information first from physicians, then by other professionals. This review has highlighted the needs and preferences to be considered in pain education interventions, which should be embedded in an approach cultivating communication and partnership with patients and their caregivers. The results still need to be confirmed with different patient populations.

Could Relationship-Based Learnt Beliefs and Expectations Contribute to Physiological Vulnerability of Chronic Pain? Making a Case to Consider Attachment in Pain Research

Pain is an interpersonal and inherently social experience. Pain perception and administration of medical treatment all occur in a particular environmental and social context. Early environmental influences and early learning experiences and interactions condition the body's response to different threats (like pain), ultimately shaping the underlying neurophysiology. These early interactions and experiences also determine what situations are perceived as threatening, as well as our belief in our own ability to self-manage, and our belief in others to offer support, during perceived threats. These beliefs intrinsically drive the combination of behaviors that emerge in response to perceived threats, including pain. Such behaviors can be categorized into attachment styles. In this interdisciplinary review, we synthesize and summarize evidence from the neurobiological, psychobiological, psychosocial, and psychobehavioral fields, to describe how these beliefs are embedded in the brain's prediction models to generate a series of expectations/perceptions around the level of safety/threat in different contexts. As such, these beliefs may predict how one experiences and responds to pain, with potentially significant implications for the development and management of chronic pain. Little attention has been directed to the effect of adult attachment style on pain in research studies and in the clinical setting. Using interdisciplinary evidence, we argue why we think this interaction merits further consideration and research. PERSPECTIVE: This review explores the influence of attachment styles on pain perception, suggesting a link between social connections and chronic pain development. It aligns with recent calls to emphasize the social context in pain research and advocates for increased focus on adult attachment styles in research and clinical practice.

Beyond pain privacy and pain meters: a new vision for pain biomarkers

To an individual, pain is unambiguously real. To a caregiver, assessing pain in others is a challenging process shrouded in doubt. To explain this challenge, many assume that pain "belongs" exclusively to the bearer of that experience and accept the dogma that pain is private. However, privacy also entails that it is not possible to identify, share, or communicate that experience with others. Obviously, this is not true and the consequences of pain privacy would be devastating for healthcare. Pain is indeed unique and subjective, but not necessarily private. Pain is in fact readily communicable, though perhaps not as effectively and reliably as caregivers would like. On the other hand, healthcare systems mandate objective metrics in pain diagnosis. Smiley face caricatures are a staple of clinical practice and a universal standard for reporting pain levels. These conditions create a double paradox: Assess a private experience that is inaccessible, and use numerical scales to measure subjective attributes. Navigating this stressful environment, medical professionals experience intellectual dissonance, patients are frustrated, and value-based care is undermined. Offering a way out, first, we refute the privacy and objectification of pain citing philosophical, behavioral, and neuroscientific arguments. We discuss Wittgensteinian views against privacy, explore the clear evolutionary advantage of communicating pain to others, and identify neural circuits in the mammalian brain that contribute to empathy. Second, we highlight the subjectivity of pain, embracing the complexity and uniqueness of an individual's pain. We also provide compelling evidence for brain mechanisms that actively shape the pain experience according to predictive coding principles. Third, we offer a vision for the development of biomarker technologies that assess pain fairly without engendering bias against the patient's narrative. Our recommendations are based on the overwhelming appreciation that "medicine by emoji" is inadequate for capturing the multidimensional nature of pain. Our view is that the most promising candidates for pain biomarkers consist of self-reports as ground truth augmented by physiological signatures of biological relevance to pain. Integration of subjective and objective multimodal features will be key for the development of comprehensive pain assessment models.

Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Verbal Support From a Stranger Reduces the Development of Mechanical Hypersensitivity: Behavioral and Neurophysiological Evidence

Hand-holding reduces experimentally induced acute pain and buffers against the development of mechanical secondary hypersensitivity, an indirect proxy of central sensitization. Here, we tested if verbal support from a stranger, a common occurrence in clinical contexts, exerts the same effects. In this preregistered study, 44 healthy female participants were assigned to an alone or support group whereby a supportive female stranger encouraged them through the painful procedure leading to secondary mechanical hypersensitivity. Mechanical hypersensitivity was measured via self-reports and by the size of the anteroposterior and mediolateral spread of mechanical hypersensitivity. We investigated the moderating role of attachment style on self-reports and the effects of support on skin conductance level, salivary cortisol, and pinprick-evoked potentials. We also tested whether theta/beta ratio in the resting-state electroencephalogram predicted mechanical hypersensitivity. Self-reported ratings and the late part of the pinprick-evoked potentials were reduced in the support group, but the spread of mechanical hypersensitivity was not. Attachment anxiety and avoidance moderated the self-reported intensity such that individuals with higher attachment anxiety and avoidance scores reported lower intensity ratings in the support group. No significant effect of the verbal support was observed on skin conductance level and salivary cortisol. The theta/beta ratio did not predict the extent of hypersensitivity. Our data indicate that, in women, verbal support during intense pain leading to hypersensitivity is effective on some behavioral outcomes, but altogether the lack of group differences in cortisol, self-reported stress, and skin conductance does not provide strong support for the stress-buffering hypothesis. PERSPECTIVE: Verbal support by a stranger during a painful procedure leading to secondary mechanical hypersensitivity attenuated the development of some measures of mechanical hypersensitivity and associated neural responses in healthy female participants. No evidence was found for the role of stress. DATA AVAILABILITY: The authors will make all data available upon request.

Pet dogs succeed where human companions fail: The presence of pet dogs reduces pain

Social support from family and friends, albeit associated with beneficial health effects, does not always help to cope with pain. This may be because humans elicit mixed expectations of social support and evaluative judgment. The present studies aimed to test whether pet dogs are a more beneficial source of support in a painful situation than human companions because they are not evaluative. For this, 74 (Study 1) and 50 (Study 2) women completed a cold-pressor task in the presence of either their own (S1) or an unfamiliar (S2) dog, a friend (S1), or an unknown human companion (S2), or alone. In both studies, participants reported less pain and exhibited less pain behavior in the presence of dogs compared to human companions. Reactions to pain were moderated by attitudes towards dogs in S2. This suggests that pet dogs may help individuals to cope with painful situations, especially if the individual in pain generally feels affectionate towards dogs.

Compassion, communication, and the perception of control: a mixed methods study to investigate patients' perspectives on clinical practices for alleviating distress and promoting empowerment during awake craniotomies

PURPOSE

To inquire into clinical practices perceived to mitigate patients' intraoperative distress during awake craniotomies.

METHODS

This mixed-methods study involved administration of Amsterdam Preoperative Anxiety and Information Scale and PTSD Checklist prior to the awake craniotomy to evaluate anxiety and information-seeking related to the procedure and symptoms of PTSD. Generalized Anxiety Disorder Scale and Depression Module of the Patient Health Questionnaire were administered before and after the procedure to evaluate generalized anxiety and depression. Patient interviews were conducted 2-weeks postprocedure and included a novel set of patient experience scales to assess patients' recollection of intraoperative pain, overall distress, anxiety, distress due to noise, perception of empowerment, perception of being well-prepared, overall satisfaction with anaesthesia management, and overall satisfaction with the procedure. Qualitative data were analysed using conventional content analysis.

RESULTS

Participants (n = 14) had undergone an awake craniotomy for tissue resection due to primary brain tumours or medically-refractory focal epilepsy. Validated self-report questionnaires demonstrated reduced levels of generalized anxiety (pre mean = 8.66; SD = 6.41; post mean= 4.36; SD = 4.24) following the awake craniotomy. Postprocedure interviews revealed very high satisfaction with the awake craniotomy and anaesthesia management and minimal levels of intraoperative pain, anxiety, and distress. The most stressful aspects of the procedure included global recognition of medical diagnosis, anxiety provoked by unfamiliar sights, sounds, and sensations, a perception of a lack of information or misinformation, and long periods of immobility. Important factors in alleviating intraoperative distress included the medical team's ability to promote patient perceptions of control, establish compassionate relationships, address unfamiliar intraoperative sensations, and deliver effective anaesthesia management.

CONCLUSION

Compassion, communication, and patient perception of control were critical in mitigating intraoperative distress. Clinical practice recommendations with implications for all clinicians involved in patient care during awake craniotomies are provided. Use of these interventions and strategies to reduce distress are important to holistic patient care and patient experiences of care and may improve the likelihood of optimal brain mapping procedures to improve clinical outcomes during awake craniotomies.

Visual psychosocial profiling of Chinese temporomandibular disorder pain patients and correlations with somatosensory function

BACKGROUND

Psychosocial function of Chinese temporomandibular disorders (TMD) pain patients and the correlation with somatosensory function has not been sufficiently studied.

OBJECTIVE

The study aims at assessing the psychosocial function of Chinese TMD pain patients by visualisation method and evaluating the correlations with somatosensory function quantitatively.

METHODS

The Symptom Checklist 90 (SCL-90) questionnaire and standardised quantitative sensory testing (QST) were administered to 70 Chinese TMD pain patients and age- and gender-matched healthy controls (HCs). Of these, 40 TMD arthralgia patients received QST before and after medication. Psychosocial and somatosensory parameters were transformed into standardised scores. Differences within groups were assessed through t tests. Correlations between psychosocial and somatosensory profiles were explored through correlation analyses with Bonferroni correction for multiple comparisons.

RESULTS

100% of the Chinese TMD pain patients exhibited psychosocial distress in contrast to HCs. Anger and hostility showed negative correlation with the thermal nonnociceptive parameter (thermal sensory limen, p =.002) and nociceptive parameters (cold pain threshold and pain pressure threshold, p<.001). Correlation analysis indicated that cold detection threshold was negatively correlated with somatization and mechanical pain sensitivity had a negative correlation with anger and hostility through medical treatment (p <.001).

CONCLUSIONS

Visual psychosocial profiles provided an easy overview of psychosocial function in Chinese TMD pain patients. Anger and hostility was associated with increased thermal nonnociceptive and nociceptive sensitivity to stimuli. Psychosocial distress might be negatively associated with TMD treatment response which indicated a possible need for psychological intervention during treatment.

Mitigating the affective and cognitive consequences of social exclusion: an integrative data analysis of seven social disconnection interventions

BACKGROUND

Being socially excluded has detrimental effects, with prolonged exclusion linked to loneliness and social isolation. Social disconnection interventions that do not require direct support actions (e.g., "how can I help?") offer promise in mitigating the affective and cognitive consequences of social exclusion. We examine how various social disconnection interventions involving friends and unknown peers might mitigate social exclusion by buffering (intervening before) and by promoting recovery (intervening after).

METHODS

We present an integrative data analysis (IDA) of five studies (N = 664) that systematically exposed participants to exclusion (vs. inclusion) social dynamics. Using a well-validated paradigm, participants had a virtual interaction with two other people. Unbeknownst to participants, the other people's behavior was programmed to either behave inclusively toward the participant or for one to behave exclusively. Critically, our social disconnection interventions experimentally manipulated whether a friend was present (vs. an unknown peer vs. being alone), the nature of interpersonal engagement (having a face-to-face conversation vs. a reminder of an upcoming interaction vs. mere presence), and the timing of the intervention in relation to the social dynamic (before vs. during vs. after). We then assessed participants' in-the-moment affective and cognitive responses, which included mood, feelings of belonging, sense of control, and social comfort.

RESULTS

Experiencing exclusion (vs. inclusion) led to negative affective and cognitive consequences. However, engaging in a face-to-face conversation with a friend before the exclusion lessened its impact (p < .001). Moreover, a face-to-face conversation with a friend after exclusion, and even a reminder of an upcoming interaction with a friend, sped-up recovery (ps < .001). There was less conclusive evidence that a face-to-face conversation with an unknown peer, or that the mere presence of a friend or unknown peer, conferred protective benefits.

CONCLUSIONS

The findings provide support for the effectiveness of social disconnection interventions that involve actual (i.e., face-to-face) or symbolic (i.e., reminders) interactions with friends. These interventions target momentary vulnerabilities that arise from social exclusion by addressing negative affect and cognitions before or after they emerge. As such, they offer a promising approach to primary prevention prior to the onset of loneliness and social isolation.

Updating beliefs about pain following advice: Trustworthiness of social advice predicts pain expectations and experience

Prior expectations influence pain experience. These expectations, in turn, rely on prior pain experience, but they may also be socially influenced. Yet, most research has focused on self rather than social expectations about pain, and hardly any studies examined their combined effects on pain. Here, we adopted a Bayesian learning perspective to investigate how explicitly communicated social expectations ('advice about pain tolerance') affect own pain expectations, and ultimately pain tolerance, under varying conditions of social epistemic uncertainty (trustworthiness of the advice). N = 72 female participants took part in a coldpressor (cold water) task before (self-learning baseline) and after (socially-influenced learning) receiving advice about their likely pain tolerance from a confederate, the trustworthiness of whom was experimentally manipulated. We used path analysis to test the hypothesis that social advice from a highly trustworthy confederate would influence participants' expectations about pain more than advice from a less trustworthy source, and that the degree of this social influence would in turn predict pain tolerance. We further used a simplified, Bayesian learning, computational approach for explicit belief updating to examine the role of latent parameters of precision optimisation in how participants subsequently changed their future pain expectations (prospective posterior beliefs) based on the combined effect of the confederate's advice on their own pain expectations, and their own task experience. Results confirmed that participants adjusted their pain expectations towards the confederate's advice more in the high- vs. low-trustworthiness condition, and this advice taking predicted their pain tolerance. Furthermore, the confederate's trustworthiness influenced how participants weighted the confederate's advice in relation to their own expectations and task experience in forming prospective posterior beliefs. When participants received advice from a less trustworthy confederate, their own sensory experience was weighted more highly than their socially-influenced prior expectations. Thus, explicit social advice appears to impact pain by influencing one's own pain expectations, but low social trustworthiness leads to these expectations becoming more malleable to novel, sensory learning.

Social support of virtual characters reduces pain perception

BACKGROUND

Psychosocial factors, such as social support, can reduce pain. Virtual reality (VR) is a powerful tool to decrease pain, but social factors in VR-based pain analgesia have rarely been studied. Specifically, it is unclear whether social support by virtual characters can reduce pain and whether the perceived control behind virtual characters (agency) and varying degrees of social cues impact pain perception.

METHODS

Healthy participants (N = 97) received heat pain stimulation while undergoing four within-subject conditions in immersive VR: (1) virtual character with a low number of social cues (virtual figure) provided verbal support, (2) virtual character with a high number of social cues (virtual human) provided verbal support, (3) no social support (hearing neutral words), (4) no social support. Perceived agency of the virtual characters served as between-subjects factor. Participants in the avatar group were led to believe that another participant controlled the virtual characters. Participants in the agent group were told they interacted with a computer. However, in both conditions, virtual characters were computer-controlled. Pain ratings, psychophysiological measurements and presence ratings were recorded.

RESULTS

Virtual social support decreased pain intensity and pain unpleasantness ratings but had no impact on electrodermal activity nor heart rate. A virtual character with a high number of social cues led to lower pain unpleasantness and higher feelings of presence. Agency had no significant impact.

CONCLUSIONS

Virtual characters providing social support can reduce pain independent of perceived agency. A more human visual appearance can have beneficial effects on social pain modulation by virtual characters.

SIGNIFICANCE

Social influences are important factors in pain modulation. The current study demonstrated analgesic effects through verbal support provided by virtual characters and investigated modulating factors. A more human appearance of a virtual character resulted in a higher reduction of pain unpleasantness. Importantly, agency of the virtual characters had no impact. Given the increasing use of digital health interventions, the findings suggest a positive impact of virtual characters for digital pain treatments.

The Effect of Everyday-Life Social Contact on Pain

Pain is a biopsychosocial phenomenon, resulting from the interplay between physiological and psychological processes and social factors. Given that humans constantly interact with others, the effect of social factors is particularly relevant. Documenting the significance of the social modulation of pain, an increasing number of studies have investigated the effect of social contact on subjective pain intensity and pain-related physiological changes. While evidence suggests that social contact can alleviate pain, contradictory findings indicate an increase in pain intensity and a deterioration of pain coping strategies. This evidence primarily stems from studies examining the effect of social contact on pain within highly controlled laboratory conditions. Moreover, pain assessments often rely on one-time subjective reports of average pain intensity across a predefined period. Ecological momentary assessments (EMAs) can circumvent these problems, as they can capture diverse aspects of behavior and experiences multiple times a day, in real time, with high resolution, and within naturalistic and ecologically valid settings. These multiple measures allow for the examination of fluctuations of pain symptoms throughout the day in relation to affective, cognitive, behavioral, and social factors. In this opinion paper, we review the current state and future relevance of EMA-based social pain research in daily life. Specifically, we examine whether everyday-life social support reduces or enhances pain. The first part of the paper provides a comprehensive overview of the use of EMA in pain research and summarizes the main findings. The review of the relatively limited number of existing EMA studies shows that the association between pain and social contact in everyday life depends on numerous factors, including pain syndromes, temporal dynamics, the nature of social interactions, and characteristics of the interaction partners. In line with laboratory research, there is evidence that everyday-life social contact can alleviate, but also intensify pain, depending on the type of social support. Everyday-life emotional support seems to reduce pain, while extensive solicitous support was found to have opposite effects. Moreover, positive short-term effects of social support can be overshadowed by other symptoms such as fatigue. Overall, gathering and integrating experiences from a patient's social environment can offer valuable insights. These insights can help interpret dynamics in pain intensity and accompanying symptoms such as depression or fatigue. We conclude that factors determining the reducing versus enhancing effects of social contact on pain need to be investigated more thoroughly. We advocate EMA as the assessment method of the future and highlight open questions that should be addressed in future EMA studies on pain and the potential of ecological momentary interventions for pain treatment.

Interpersonal physiological and psychological synchrony predict the social transmission of nocebo hyperalgesia between individuals

Witnessing another's pain can heighten pain in the observer. However, research has focused on the observer's intrapersonal experience. Here, a social transmission-chain explored the spread of socially-acquired nocebo hyperalgesia. Dyads of genuine participants were randomised to 'Generations' (G1-G3). G1-Demonstrators, observed by G2-Observers, experienced high/low thermal pain contingent on supposed activity/inactivity of a sham-treatment. G2 became Demonstrators, witnessed by G3-Observers. They experienced fixed low-temperature stimuli irrespective of sham-treatment 'activity'. G3 then Demonstrated for G4-Observers (a confederate), also experiencing low-temperature stimuli only. Pain ratings, electrodermal activity, and facial action units were measured. G1's treatment-related pain propagated throughout the chain. G2 and G3 participants showed heightened subjective and physiological response to sham-treatment, despite equivalent stimulus temperatures, and G3 never witnessing the initial pain-event. Dyadic interpersonal physiological synchrony (electrodermal activity) and psychological synchrony (Observer's ability to predict the Demonstrator's pain), predicted subsequent socially-acquired pain. Implications relate to the interpersonal spread of maladaptive pain experiences.

Vague sensations. About the background and consequences of discordance between actual and perceived physiological changes

Empirical evidence consistently shows that discordance, also called dissociation or discrepancy, between actual physiological (mainly visceral) events and their perceived counterparts is substantial. On the one hand, we typically do not perceive actual visceral events occurring in our bodies; on the other hand, sometimes we do perceive bodily changes that do not really take place. This narrative review presents the available empirical findings on the discordance, and summarizes possible explanations that approach the phenomenon from the viewpoint of evolution, cognitive development, and predictive processing. Also, the role of top-down factors, such as expectations and experiences is discussed. Finally, practically relevant consequences of the discordance are presented using the examples of mind-body practices, the placebo and nocebo phenomenon, and medically unexplained symptoms. It is concluded that the discordance between actual and perceived body changes can have a negative impact on health, mainly through issues with adherence and other behavioral factors. The existence of actual-perceived discordance should be taught and demonstrated in the elementary and high school, as well as in many areas of higher education.

Investigating psychological mechanisms linking pain severity to depression symptoms in women cancer survivors at a cancer center with a rural catchment area

PURPOSE

Women cancer survivors, especially those in rural areas, with high levels of depression may be acutely susceptible to pain due to the ways they think, feel, and behave. The current study seeks to elucidate the relationship between symptoms of depression and pain severity in women cancer survivors, by examining the putative mediators involved in this relationship, specifically their self-efficacy for managing their health, how overwhelmed they were from life's responsibilities, and relational burden.

METHODS

Self-report data were collected from 183 cancer survivors of breast, cervical, ovarian, or endometrial/uterine cancer, who were between 6 months and 3 years post-active therapy.

RESULTS

Women cancer survivors with higher (vs. lower) symptoms of depression had more severe pain. Individual mediation analyses revealed that survivors with higher levels of depression felt more overwhelmed by life's responsibilities and had lower self-efficacy about managing their health, which was associated with greater pain severity. When all mediators were simultaneously entered into the same model, feeling overwhelmed by life's responsibilities significantly mediated the link between survivors' symptoms of depression and their pain severity.

CONCLUSIONS

The relationship between symptoms of depression and pain severity in women cancer survivors may be attributed in part to their self-efficacy and feeling overwhelmed by life's responsibilities. Early and frequent assessment of psychosocial factors involved in pain severity for women cancer survivors may be important for managing their pain throughout the phases of cancer survivorship.

Prevalence, correlates, and quality-of-life outcomes of major or persistent pain among women living with HIV in Metro Vancouver, Canada

While women living with HIV (WLWH) are twice as likely to report severe or undertreated chronic pain compared to men, little is known about pain among WLWH. Our goal was to characterize the correlates of pain as well as its impact on quality-of-life outcomes among women enrolled in the Sexual Health and HIV/AIDS Women's Longitudinal Needs Assessment (SHAWNA), an open longitudinal study of WLWH accessing care in Metro Vancouver, Canada. We conducted logistic regression analyses to identify associations between self-reported major or persistent pain with sociostructural and psychosocial correlates and with quality-of-life outcomes. Data are presented as adjusted odds ratios (aORs) with 95% confidence intervals. Among 335 participants, 77.3% reported pain at ≥ 1 study visit, with 46.3% experiencing any undiagnosed pain and 53.1% managing pain with criminalized drugs. In multivariable analysis, age (aOR 1.04[1.03-1.06] per year increase), food and housing insecurity (aOR 1.54[1.08-2.19]), depression diagnosis (aOR 1.34[1.03-1.75]), suicidality (aOR 1.71[1.21-2.42]), and non-daily, non-injection opioid use (aOR 1.53[1.07-2.17]) were associated with higher odds of pain. Daily non-injection opioid use (aOR 0.46[0.22-0.96]) and health services access (aOR 0.63[0.44-0.91]) were associated with lower odds of pain. In separate multivariable confounder models, pain was associated with reduced odds of good self-rated health (aOR 0.64[0.48-0.84] and increased odds of health interference with social activities (aOR 2.21[1.63-2.99]) and general function (aOR 3.24[2.54-4.13]). In conclusion, most WLWH in our study reported major or persistent pain. Pain was commonly undiagnosed and associated with lower quality of life. We identified structural and psychosocial factors associated with pain in WLWH, emphasizing the need for low-barrier, trauma-informed, and harm reduction-based interventions.

Interoceptive technologies for psychiatric interventions: From diagnosis to clinical applications

Interoception-the perception of internal bodily signals-has emerged as an area of interest due to its implications in emotion and the prevalence of dysfunctional interoceptive processes across psychopathological conditions. Despite the importance of interoception in cognitive neuroscience and psychiatry, its experimental manipulation remains technically challenging. This is due to the invasive nature of existing methods, the limitation of self-report and unimodal measures of interoception, and the absence of standardized approaches across disparate fields. This article integrates diverse research efforts from psychology, physiology, psychiatry, and engineering to address this oversight. Following a general introduction to the neurophysiology of interoception as hierarchical predictive processing, we review the existing paradigms for manipulating interoception (e.g., interoceptive modulation), their underlying mechanisms (e.g., interoceptive conditioning), and clinical applications (e.g., interoceptive exposure). We suggest a classification for interoceptive technologies and discuss their potential for diagnosing and treating mental health disorders. Despite promising results, considerable work is still needed to develop standardized, validated measures of interoceptive function across domains and before these technologies can translate safely and effectively to clinical settings.

The impact of the social context on the development of secondary hyperalgesia: an experimental study

ABSTRACT

Social support has been shown to reduce pain ratings and physiological responses to acute pain stimuli. Furthermore, this relationship is moderated by adult attachment styles. However, these effects have not been characterized in experimentally induced symptoms of chronic pain, such as secondary hyperalgesia (SH) which is characterized by an increased sensitivity of the skin surrounding an injury. We aimed to examine whether social support by handholding from a romantic partner can attenuate the development of experimentally induced SH. Thirty-seven women, along with their partners, participated in 2 experimental sessions 1 week apart. In both sessions, SH was induced using an electrical stimulation protocol. In the support condition, the partner was seated across from the participant holding the participant's hand during the electrical stimulation, whereas in the alone condition, the participant went through the stimulation alone. Heart rate variability was measured for both the participant as well as the partner before, during, and after the stimulation. We found that the width of the area of hyperalgesia was significantly smaller in the support condition. Attachment styles did not moderate this effect of social support on the area width. Increasing attachment avoidance was associated with both a smaller width of hyperalgesia and a smaller increase in the sensitivity on the stimulated arm. For the first time, we show that social support can attenuate the development of secondary hyperalgesia and that attachment avoidance may be associated with an attenuated development of secondary hyperalgesia.

Chronic pain patients low in social connectedness report higher pain and need deeper pressure for pain relief

The experience of rejection and disconnection reliably amplifies pain. Yet, little is known about the impact of enduring feelings of closeness, or social connectedness, on experiences of chronic pain. The current secondary analysis tested the hypothesis that greater social connectedness would predict lower chronic pain ratings, mediated by lower depression and anxiety. In addition, based on the social-affective effects of deeper pressure, and our previous finding that deeper pressure from a weighted blanket reduced chronic pain ratings, we examined whether deeper pressure from a weighted blanket would induce greater pain relief in socially disconnected chronic pain patients. We assessed social connectedness, anxiety, and depression at baseline and pain levels before and after a remote, 7-day randomized-controlled trial of a heavy or light (control) weighted blanket in a predominately White (86%) and female (80%) sample of 95 chronic pain patients. Results revealed that lower social connectedness was associated with higher chronic pain ratings, which was mediated by anxiety, but not depression. Pressure level (light vs. deep) moderated associations between social connectedness and pain reductions, such that deeper pressure was necessary for pain relief in the most socially disconnected participants. Our findings suggest a close relationship between social connectedness and chronic pain through a mechanistic pathway of anxiety. Furthermore, our findings demonstrate that sensory-affective interventions such as a weighted blanket may be a beneficial tool for chronic pain sufferers who are prone to social disconnection, potentially by activating embodied representations of safety and social support. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Pain: Behavioural expression and response in an evolutionary framework

An evolutionary perspective offers insights into the major public health problem of chronic (persistent) pain; behaviours associated with it perpetuate both pain and disability. Pain is motivating, and pain-related behaviours promote recovery by immediate active or passive defence; subsequent protection of wounds; suppression of competing responses; energy conservation; vigilance to threat; and learned avoidance of associated cues. When these persist beyond healing, as in chronic pain, they are disabling. In mammals, facial and bodily expression of pain is visible and identifiable by others, while social context, including conspecifics' responses, modulate pain. Studies of responses to pain emphasize onlooker empathy, but people with chronic pain report feeling disbelieved and stigmatized. Observers frequently discount others' pain, best understood in terms of cheater detection-alertness to free riders that underpins the capacity for prosocial behaviours. These dynamics occur both in everyday life and in clinical encounters, providing an account of the adaptiveness of pain-related behaviours.

Familiarity From Facial Appearance Leads to Hypoalgesia

Social context has been shown to influence pain perception. This study aimed to broaden this literature by investigating whether relevant social stimuli, such as faces with different levels of intrinsic (based on physical resemblance to known individuals) and episodic (acquired through a previous experience) familiarity, may lead to hypoalgesia. We hypothesized that familiarity, whether intrinsic or acquired through experience, would increase pain threshold and decrease pain intensity. Sixty-seven participants underwent pain induction (the cold pressor test) viewing previously seen faces (Episodic Group) or new faces (Non-episodic Group) that differed in the level of intrinsic familiarity (high vs low). Pain threshold was measured in seconds, while pain intensity was measured on a rating scale of 0 to 10. The results did not show an effect of episodic familiarity. However, compared to low, high intrinsic familiar faces had an attenuating effect on pain intensity, even after controlling for pain expectation. These results suggest that physical features conveying a higher feeling of familiarity induce a top-down hypoalgesic modulation, in line with the idea that familiarity may signal safety and that the presence of familiar others reduce perceived threat-related distress. This study provides further evidence on the social modulation of pain and contributes to the literature on first impressions' influence on social behavior. PERSPECTIVE: Consistent with the idea that familiar others signal safety and reduce the sense of threat, facial features conveying familiarity induce a top-down hypoalgesic modulation. This knowledge may contribute to understanding differences in pain perception in experimental and clinical contexts.

Cultural Framing and the Impact On Acute Pain and Pain Services

PURPOSE OF REVIEW

Optimal treatment requires a thorough understanding of all factors contributing to pain in the individual patient. In this review, we investigate the influence of cultural frameworks on pain experience and management.

RECENT FINDINGS

The loosely defined concept of culture in pain management integrates a predisposing set of diverse biological, psychological and social characteristics shared within a group. Cultural and ethnic background strongly influence the perception, manifestation, and management of pain. In addition, cultural, racial and ethnic differences continue to play a major role in the disparate treatment of acute pain. A holistic and culturally sensitive approach is likely to improve pain management outcomes, will better cover the needs of diverse patient populations and help reduce stigma and health disparities. Mainstays include awareness, self-awareness, appropriate communication, and training.

Placebo and Nocebo Effects as Bayesian-Brain Phenomena: The Overlooked Role of Likelihood and Attention

The Bayesian-brain framework applied to placebo responses and other mind-body interactions suggests that the effects on the body result from the interaction between priors, such as expectations and learning, and likelihood, such as somatosensorial information. Significant research in this area focuses on the role of the priors, but the relevance of the likelihood has been surprisingly overlooked. One way of manipulating the relevance of the likelihood is by paying attention to sensorial information. We suggest that attention can influence both precision and position (i.e., the relative distance from the priors) of the likelihood by focusing on specific components of the somatosensorial information. Two forms of attention seem particularly relevant in this framework: mindful attention and selective attention. Attention has the potential to be considered a "major player" in placebo/nocebo research, together with expectations and learning. In terms of application, relying on attentional strategies as "amplifiers" or "silencers" of sensorial information could lead to an active involvement of individuals in shaping their care process and health. In this contribution, we discuss the theoretical implications of these intuitions with the aim to provide a comprehensive framework that includes Bayesian brain, placebo/nocebo effects, and the role of attention in mind-body interactions.

When Musculoskeletal Clinicians Respond to Empathetic Opportunities, do Patients Perceive Greater Empathy?

BACKGROUND

Patient use of verbal and nonverbal communication to signal what is most important to them can be considered empathetic opportunities. Orthopaedic surgeons may have mixed feelings toward empathetic opportunities, on one hand wanting the patient to know that they care, and on the other hand fearing offense, prolonged visit duration, or discussions for which they feel ill prepared. Evidence that action about empathetic opportunities does not harm the patient's experience or appreciably prolong the visit could increase the use of these communication tactics with potential for improved experience and outcomes of care.

QUESTIONS/PURPOSES

Using transcripts from musculoskeletal specialty care visits in prior studies, we asked: (1) Are there factors, including clinician attentiveness to empathetic opportunities, associated with patient perception of clinician empathy? (2) Are there factors associated with the number of patient-initiated empathetic opportunities? (3) Are there factors associated with clinician acknowledgment of empathetic opportunities? (4) Are there factors associated with the frequency with which clinicians elicited empathetic opportunities?

METHODS

This study was a retrospective, secondary analysis of transcripts from prior studies of audio and video recordings of patient visits with musculoskeletal specialists. Three trained observers identified empathetic opportunities in 80% (209 of 261) of transcripts of adult patient musculoskeletal specialty care visits, with any uncertainties or disagreements resolved by discussion and a final decision by the senior author. Patient statements considered consistent with empathetic opportunities included relation of emotion, expression of worries or concerns, description of loss of valued activities or loss of important roles or identities, relation of a troubling psychologic or social event, and elaboration on daily life. Clinician-initiated empathetic opportunities were considered clinician inquiries about these factors. Clinician acknowledgment of empathetic opportunities included encouragement, affirmation or reassurance, or supportive statements. Participants completed post-visit surveys of perceived clinician empathy, symptoms of depression, and health anxiety. Factors associated with perceived clinician empathy, number of empathetic opportunities, clinician responses to these opportunities, and the frequency with which clinicians elicited empathetic opportunities were sought in bivariate and multivariable analyses.

RESULTS

After controlling for potentially confounding variables such as working status and pain self-efficacy scores in the multivariable analysis, no factors were associated with patient perception of clinician empathy, including attentiveness to empathetic opportunities. Patient-initiated empathetic opportunities were modestly associated with longer visit duration (correlation coefficient 0.037 [95% confidence interval 0.023 to 0.050]; p < 0.001). Clinician acknowledgment of empathetic opportunities was modestly associated with longer visit duration (correlation coefficient 0.06 [95% CI 0.03 to 0.09]; p < 0.001). Clinician-initiated empathetic opportunities were modestly associated with younger patient age (correlation coefficient -0.025 [95% CI -0.037 to -0.014]; p < 0.001) and strongly associated with one specific interviewing clinician as well as other clinicians (correlation coefficient -1.3 [95% CI -2.2 to -0.42]; p = 0.004 and -0.53 [95% CI -0.95 to -0.12]; p = 0.01).

CONCLUSION

Musculoskeletal specialists can respond to empathic opportunities without harming efficiency, throughput, or patient experience.

CLINICAL RELEVANCE

Given the evidence that patients prioritize feeling heard and understood, and evidence that a trusting patient-clinician relationship is protective and healthful, the results of this study can motivate specialists to train and practice effective communication tactics.

Pain perception and physiological responses are modulated by active support from a romantic partner

As social animals, humans are strongly affected by social bonds and interpersonal interactions. Proximity and social support from significant others may buffer the negative outcomes of a painful experience. Several studies have investigated the role of romantic partners' support in pain modulation, mostly focusing on tactile support and showing its effectiveness in reducing pain perception. Nevertheless, no study so far has investigated the role of supportive speaking on pain modulation, nor has compared the effects of a tactile and vocal support within the same couples. The present study directly compared for the first time the efficacy of mere presence (Passive Support) and different forms of active (Touch, Voice, Touch + Voice) support from a romantic partner during a painful experience in a naturalistic setting. We assessed pain modulation in 37 romantic couples via both subjective (self-reported ratings) and physiological (skin conductance) measurements. We found that all three types of active support were equally more effective than passive support in reducing the painful experience at both subjective and physiological levels; interestingly, our results suggest that supportive speaking can reduce pain perception with respect to passive support to a similar extent as tactile support does. Overall, this study highlights the relevance of an active support in reducing pain perception, with active types of support being more effective than passive support, regardless of its specific modality.

The Relationship between Nociceptive Detection Thresholds and Pressure- and Electrical Pain Thresholds: An Explorative Study in Rheumatoid Arthritis Patients

Recently, methods have been developed enabling the characterization of the nociceptive function at the detection threshold level by measuring nociceptive detection thresholds (NDTs), rather than at the level of the pain threshold via pain threshold (PT) measurements. Both NDT and PT measurements aim to characterize (parts of) the nociceptive system. To date it is unclear if, and if so to what extent, the two outcomes relate to one another. In this study, the primary aim is to explore the relationship between the two measures in patients with rheumatoid arthritis (RA). As secondary aim, we explore differences in NDT between these RA patients with age- and sex-matched healthy controls (HC) from a readily existing dataset. In total 46 RA patients have been recruited, whereby the pressure- (PPT; bilaterally at two locations) and electrical (EPT) pain threshold were evaluated, as well as the NDTs. Significant, positive correlations were found between the EPT and PPT (R=0.54-0.60), but not with the NDTs (R≤0.25). As compared to HC, higher NDTs were found in the RA group. As the presence of a statistically significant weak relationship can only be evaluated using a larger sample size, our results indicate that there is no moderate or stronger relation between PT and NDT outcomes. This implicates that the two outcomes are not strongly driven by the same (nociceptive) mechanism(s). Future research into NDTs and what factors and/or mechanisms affect the outcome, could yield relevant insights into how to use and interpret the results of this relatively new method.Clinical Relevance - The evaluation of nociceptive detection thresholds, in isolation or together with conventionally evaluated pain thresholds, might provide valuable and complementary insights into nociceptive (dis)function in man.

The effects of everyday-life social interactions on anxiety-related autonomic responses differ between men and women

Social buffering, a phenomenon where social presence can reduce anxiety and fear-related autonomic responses, has been studied in numerous laboratory settings. The results suggest that the familiarity of the interaction partner influences social buffering while also providing some evidence for gender effects. In the laboratory, however, it is difficult to mimic the complexity of real-life social interactions. Consequently, the social modulation of anxiety and related autonomic responses in everyday life remains poorly understood. We used smartphone-based Ecological Momentary Assessment (EMA) combined with wearable electrocardiogram sensors to investigate how everyday-life social interactions affect state anxiety and related cardiac changes in women and men. On five consecutive days, 96 healthy young participants (53% women) answered up to six EMA surveys per day, indicating characteristics of their most recent social interaction and the respective interaction partner(s). In women, our results showed lower heart rate in the presence of a male interaction partner. Men showed the same effect with female interaction partners. Moreover, only women showed decreased heart rate and increased heart rate variability with increasing interaction partner familiarity. These findings specify the conditions under which social interactions reduce anxiety-related responses in women and men.

Neurophysiological and Psychosocial Mechanisms of Fibromyalgia: A Comprehensive Review and Call for An Integrative Model

Research into the neurobiological and psychosocial mechanisms involved in fibromyalgia has progressed remarkably in recent years. Despite this, current accounts of fibromyalgia fail to capture the complex, dynamic, and mutual crosstalk between neurophysiological and psychosocial domains. We conducted a comprehensive review of the existing literature in order to: a) synthesize current knowledge on fibromyalgia; b) explore and highlight multi-level links and pathways between different systems; and c) build bridges connecting disparate perspectives. An extensive panel of international experts in neurophysiological and psychosocial aspects of fibromyalgia discussed the collected evidence and progressively refined and conceptualized its interpretation. This work constitutes an essential step towards the development of a model capable of integrating the main factors implicated in fibromyalgia into a single, unified construct which appears indispensable to foster the understanding, assessment, and intervention for fibromyalgia.

Exploring the role of empathy in prolonged grief reactions to bereavement

Grief reactions to the bereavement of a close individual could involve empathy for pain, which is fundamental to social interaction. To explore whether grief symptoms interact with social relatedness to a person to whom one directs empathy to modulate the expression of empathy, we administered an empathy task to 28 bereaved adults during functional magnetic resonance imaging, in which participants were subliminally primed with facial stimuli (e.g., faces of their deceased or living relative, or a stranger), each immediately followed by a visual pain stimulus. Individuals' grief severity promoted empathy for the pain stimulus primed with the deceased's face, while it diminished the neural response to the pain stimulus primed with the face of either their living relative or a stranger in the medial frontal cortex (e.g., the right dorsal anterior cingulate cortex). Moreover, preliminary analyses showed that while the behavioral empathic response was promoted by the component of "longing" in the deceased priming condition, the neural empathic response was diminished by the component of "avoidance" in the stranger priming condition. Our results suggest an association between grief reactions to bereavement and empathy, in which grief symptoms interact with interpersonal factors to promote or diminish empathic responses to others' pain.

Does Level of Social Support During Rejection Affect Pain Sensitivity and Distress?

This study investigated whether level of social support would decrease emotional distress and physical pain sensitivity following rejection. Healthy undergraduate students received varying levels of social support from a close companion during the Partial Future Life Alone rejection paradigm. Participants also completed baseline and post-stressor measures of physical pain sensitivity as well as post-stressor measures of emotional distress. Results indicated that all levels of social support benefited rejected participants by either buffering and/or improving fundamental needs, mood, and pain to levels comparable to non-rejected participants; however, passive support resulted in the fewest beneficial outcomes. The current study provides preliminary evidence that even minimal levels of support during rejection benefits or at least neutralizes associated pain and distress outcomes.

Doctor trustworthiness influences pain and its neural correlates in virtual medical interactions

Trust is an important component of the doctor-patient relationship and is associated with improved patient satisfaction and health outcomes. Previously, we reported that patient feelings of trust and similarity toward their clinician predicted reductions in evoked pain in response to painful heat stimulations. In the present study, we investigated the brain mechanisms underlying this effect. We used face stimuli previously developed using a data-driven computational modeling approach that differ in perceived trustworthiness and superimposed them on bodies dressed in doctors' attire. During functional magnetic resonance imaging, participants (n = 42) underwent a series of virtual medical interactions with these doctors during which they received painful heat stimulation as an analogue of a painful diagnostic procedure. Participants reported increased pain when receiving painful heat stimulations from low-trust doctors, which was accompanied by increased activity in pain-related brain regions and a multivariate pain-predictive neuromarker. Findings suggest that patient trust in their doctor may have tangible impacts on pain and point to a potential brain basis for trust-related reductions in pain through the modulation of brain circuitry associated with the sensory-discriminative and affective-motivational dimensions of pain.

Therapeutic touch and therapeutic alliance in pediatric care and neonatology: An active inference framework

Therapeutic affective touch has been recognized as essential for survival, nurturing supportive interpersonal interactions, accelerating recovery-including reducing hospitalisations, and promoting overall health and building robust therapeutic alliances. Through the lens of active inference, we present an integrative model, combining therapeutic touch and communication, to achieve biobehavioural synchrony. This model speaks to how the brain develops a generative model required for recovery, developing successful therapeutic alliances, and regulating allostasis within paediatric manual therapy. We apply active inference to explain the neurophysiological and behavioural mechanisms that underwrite the development and maintenance of synchronous relationships through touch. This paper foregrounds the crucial role of therapeutic touch in developing a solid therapeutic alliance, the clinical effectiveness of paediatric care, and triadic synchrony between health care practitioner, caregiver, and infant in a variety of clinical situations. We start by providing a brief overview of the significance and clinical role of touch in the development of social interactions in infants; facilitating a positive therapeutic alliance and restoring homeostasis through touch to allow a more efficient process of allostatic regulation. Moreover, we explain the role of CT tactile afferents in achieving positive clinical outcomes and updating prior beliefs. We then discuss how touch is implemented in treatment sessions to promote cooperative interactions in the clinic and facilitate theory of mind. This underwrites biobehavioural synchrony, epistemic trust, empathy, and the resolution of uncertainty. The ensuing framework is underpinned by a critical application of the active inference framework to the fields of pediatrics and neonatology.

Social reappraisal of emotions is linked with the social presence effect in the default mode network

Introduction

Social reappraisal, during which one person deliberately tries to regulate another's emotions, is a powerful cognitive form of social emotion regulation, crucial for both daily life and psychotherapy. The neural underpinnings of social reappraisal include activity in the default mode network (DMN), but it is unclear how social processes influence the DMN and thereby social reappraisal functioning. We tested whether the mere presence of a supportive social regulator had an effect on the DMN during rest, and whether this effect in the DMN was linked with social reappraisal-related neural activations and effectiveness during negative emotions.

Methods

A two-part fMRI experiment was performed, with a psychotherapist as the social regulator, involving two resting state (social, non-social) and two task-related (social reappraisal, social no-reappraisal) conditions.

Results

The psychotherapist's presence enhanced intrinsic functional connectivity of the dorsal anterior cingulate (dACC) within the anterior medial DMN, with the effect positively related to participants' trust in psychotherapists. Secondly, the social presence-induced change in the dACC was related with (a) the social reappraisal-related activation in the bilateral dorsomedial/dorsolateral prefrontal cortex and the right temporoparietal junction and (b) social reappraisal success, with the latter relationship moderated by trust in psychotherapists.

Conclusion

Results demonstrate that a psychotherapist's supportive presence can change anterior medial DMN's intrinsic connectivity even in the absence of stimuli and that this DMN change during rest is linked with social reappraisal functioning during negative emotions. Data suggest that trust-dependent social presence effects on DMN states are relevant for social reappraisal-an idea important for daily-life and psychotherapy-related emotion regulation.

Sensitivity to movement-evoked pain, central sensitivity symptoms, and pro-nociceptive profiles in people with chronic shoulder pain: A parallel-group cross-sectional investigation

OBJECTIVE

To investigate whether sensitivity to movement-evoked pain (SMEP), central sensitivity symptom burden, and quantitative sensory testing (QST) outcomes differ between healthy controls and people with chronic shoulder pain.

METHODS

People with chronic shoulder pain (n = 39) and healthy controls (n = 26) completed validated questionnaires measuring demographic, pain characteristics, psychological factors, social support, sleep quality, central sensitivity inventory (CSI), and physical activity levels. A blinded assessor administered QST measuring pressure pain threshold, temporal summation, conditioned pain modulation, and cold hyperalgesia. All participants performed repeated lifting of weighted canisters and reported severity of pain over successive lifts of the weighted canisters. Between-group differences in the QST, SMEP and CSI scores were investigated. Demographic and psychosocial variables were adjusted in the analyses.

RESULTS

Dynamic mechanical allodynia, mechanical temporal summation, movement-evoked pain scores, SMEP index, and CSI scores were significantly (p ≤ 0.05) higher in the chronic shoulder pain group than in healthy controls. A significant proportion of people with chronic shoulder pain presented with pro-nociceptive profiles and experienced higher pain severity, interference, and disability.

CONCLUSIONS

People with chronic shoulder pain displayed symptoms and signs of central sensitization. Future research should investigate the predictive role of central sensitization on clinical outcomes in shoulder pain.

Computational psychiatry: from synapses to sentience

This review considers computational psychiatry from a particular viewpoint: namely, a commitment to explaining psychopathology in terms of pathophysiology. It rests on the notion of a generative model as underwriting (i) sentient processing in the brain, and (ii) the scientific process in psychiatry. The story starts with a view of the brain-from cognitive and computational neuroscience-as an organ of inference and prediction. This offers a formal description of neuronal message passing, distributed processing and belief propagation in neuronal networks; and how certain kinds of dysconnection lead to aberrant belief updating and false inference. The dysconnections in question can be read as a pernicious synaptopathy that fits comfortably with formal notions of how we-or our brains-encode uncertainty or its complement, precision. It then considers how the ensuing process theories are tested empirically, with an emphasis on the computational modelling of neuronal circuits and synaptic gain control that mediates attentional set, active inference, learning and planning. The opportunities afforded by this sort of modelling are considered in light of in silico experiments; namely, computational neuropsychology, computational phenotyping and the promises of a computational nosology for psychiatry. The resulting survey of computational approaches is not scholarly or exhaustive. Rather, its aim is to review a theoretical narrative that is emerging across subdisciplines within psychiatry and empirical scales of investigation. These range from epilepsy research to neurodegenerative disorders; from post-traumatic stress disorder to the management of chronic pain, from schizophrenia to functional medical symptoms.

The Role of the Skin in Interoception: A Neglected Organ?

In the past 2 decades, interoception has received increasing attention in the fields of psychology and cognitive science, as well as neuroscience and physiology. A plethora of studies adopted the perception of cardiac signals as a proxy for interoception. However, recent findings have cast doubt on the methodological and intrinsic validity of the tasks used thus far. Therefore, there is an ongoing effort to improve the existing cardiac interoceptive tasks and to identify novel channels to target the perception of the physiological state of the body. Amid such scientific abundancy, one could question whether the field has been partially neglecting one of our widest organs in terms of dimensions and functions: the skin. According to some views grounded on anatomical and physiological evidence, skin-mediated signals such as affective touch, pain, and temperature have been redefined as interoceptive. However, there is no agreement in this regard. Here, we discuss some of the anatomical, physiological, and experimental arguments supporting the scientific study of interoception by means of skin-mediated signals. We argue that more attention should be paid to the skin as a sensory organ that monitors the bodily physiological state and further propose thermosensation as a particularly attractive model of skin-mediated interoception.

Emotion regulation and the salience network: a hypothetical integrative model of fibromyalgia

Fibromyalgia is characterized by widespread pain, fatigue, sleep disturbances and other symptoms, and has a substantial socioeconomic impact. Current biomedical and psychosocial treatments are unsatisfactory for many patients, and treatment progress has been hindered by the lack of a clear understanding of the pathogenesis of fibromyalgia. We present here a model of fibromyalgia that integrates current psychosocial and neurophysiological observations. We propose that an imbalance in emotion regulation, reflected by an overactive 'threat' system and underactive 'soothing' system, might keep the 'salience network' (also known as the midcingulo-insular network) in continuous alert mode, and this hyperactivation, in conjunction with other mechanisms, contributes to fibromyalgia. This proposed integrative model, which we term the Fibromyalgia: Imbalance of Threat and Soothing Systems (FITSS) model, should be viewed as a working hypothesis with limited supporting evidence available. We hope, however, that this model will shed new light on existing psychosocial and biological observations, and inspire future research to address the many gaps in our knowledge about fibromyalgia, ultimately stimulating the development of novel therapeutic interventions.

Classification of elderly pain severity from automated video clip facial action unit analysis: A study from a Thai data repository

Data from 255 Thais with chronic pain were collected at Chiang Mai Medical School Hospital. After the patients self-rated their level of pain, a smartphone camera was used to capture faces for 10 s at a one-meter distance. For those unable to self-rate, a video recording was taken immediately after the move that causes the pain. The trained assistant rated each video clip for the pain assessment in advanced dementia (PAINAD). The pain was classified into three levels: mild, moderate, and severe. OpenFace^© was used to convert the video clips into 18 facial action units (FAUs). Five classification models were used, including logistic regression, multilayer perception, naïve Bayes, decision tree, k-nearest neighbors (KNN), and support vector machine (SVM). Out of the models that only used FAU described in the literature (FAU 4, 6, 7, 9, 10, 25, 26, 27, and 45), multilayer perception is the most accurate, at 50%. The SVM model using FAU 1, 2, 4, 7, 9, 10, 12, 20, 25, and 45, and gender had the best accuracy of 58% among the machine learning selection features. Our open-source experiment for automatically analyzing video clips for FAUs is not robust for classifying pain in the elderly. The consensus method to transform facial recognition algorithm values comparable to the human ratings, and international good practice for reciprocal sharing of data may improve the accuracy and feasibility of the machine learning's facial pain rater.

The influence of social signals on the self-experience of pain: A neuroimaging review

Researchers in cognitive neuroscience have investigated extensively how psychological factors shape the processing and perception of pain using behavioral, physiological, and neuroimaging methods. However, social influences of pain, an essential part of biopsychosocial pain models, have received relatively little attention. This is particularly true for the neurobiological mechanisms underlying social modulations on pain. Therefore, this review discusses the findings of recent neuroimaging studies measuring the effects of social manipulations on pain perception (e.g., verbal and non-verbal social signals, social interaction style, conformity, social support, and sociocultural mediators). Finally, a schematic summary of the different social modulatory themes is presented.

Therapeutic Alliance as Active Inference: The Role of Therapeutic Touch and Biobehavioural Synchrony in Musculoskeletal Care

Touch is recognised as crucial for survival, fostering cooperative communication, accelerating recovery, reducing hospital stays, and promoting overall wellness and the therapeutic alliance. In this hypothesis and theory paper, we present an entwined model that combines touch for alignment and active inference to explain how the brain develops "priors" necessary for the health care provider to engage with the patient effectively. We appeal to active inference to explain the empirically integrative neurophysiological and behavioural mechanisms that underwrite synchronous relationships through touch. Specifically, we offer a formal framework for understanding - and explaining - the role of therapeutic touch and hands-on care in developing a therapeutic alliance and synchrony between health care providers and their patients in musculoskeletal care. We first review the crucial importance of therapeutic touch and its clinical role in facilitating the formation of a solid therapeutic alliance and in regulating allostasis. We then consider how touch is used clinically - to promote cooperative communication, demonstrate empathy, overcome uncertainty, and infer the mental states of others - through the lens of active inference. We conclude that touch plays a crucial role in achieving successful clinical outcomes and adapting previous priors to create intertwined beliefs. The ensuing framework may help healthcare providers in the field of musculoskeletal care to use hands-on care to strengthen the therapeutic alliance, minimise prediction errors (a.k.a., free energy), and thereby promote recovery from physical and psychological impairments.

Exploring patient experiences of participating in a real and sham dry cupping intervention for nonspecific low back pain: A qualitative study

Background

The current quality of evidence supporting dry cupping for individuals with chronic low back pain (CLBP) is low and suggests that nonspecific factors impact experiences reported by patients. Therefore, this study assessed the impacts of social and professional support on the experience of individuals with CLBP treated with dry cupping or sham.

Method

This is an observational study with qualitative approach. Twenty-four individuals with CLBP who received dry cupping or sham in a previous clinical trial were invited. Data was collected using a semi-structured interview conducted by a trained researcher. Content analysis was used to analyze experiences, systematic procedures, and description of the content of messages. The dimensions of “pain”, “general perceptions”, and “perceived social and professional support” guided the analysis.

Results

Answers of both groups converged on similar perceptions, especially regarding pain. Physical condition was the most fragile aspect. We also observed an influence of perceived social and professional support on painful symptoms. Thus, the experience of individuals with CLBP treated with dry cupping or sham indicated that factors related to social and professional support impacted results.

Conclusions

We observed that individuals with CLBP reported similar perceptions of the effects of dry cupping or sham treatment, indicating that contextual factors may influence the perception of these individuals regarding the treatment received.

The skin conductance response indicating pain relief is independent of self or social influence on pain

Pain relief is defined as the ease of pain and is thus highly relevant for clinical applications and everyday life. Given that pain relief is based on the cessation of an aversive pain experience, it is reasonable to assume that pain relief learning would also be shaped by factors that alter subjective and physiological pain responses, such as social presence or a feeling of control. To date, it remains unclear whether and how factors that shape autonomic pain responses might affect pain relief learning. Here, we investigated how pain relief learning is shaped by two important factors known to modulate pain responses, i.e. social influence and controllability of pain. Skin conductance responses (SCRs) were recorded while participants learned to associate a formerly neutral stimulus with pain relief under three different pain conditions. In the social‐influence condition (N = 34), the pain stimulation could be influenced by another person’s decisions. In the self‐influence condition (N = 31), the participants themselves could influence the pain stimulation. Finally, in the no‐influence condition (N = 32), pain stimulation was simply delivered without any influence. According to our results, the SCRs elicited by the stimulus that was associated with pain relief were significantly smaller compared to the SCRs elicited by a neutral control stimulus, indicating pain relief learning. However, there was no significant difference in the pain relief learning effect across the groups. These results suggest that physiological pain relief learning in humans is not significantly influenced by social influence and pain controllability.

The contents of this page will be shown on the eTOC on the online version only. It will not be published as part of the article PDF. Subjective and physiological pain responses can be altered by social support or pain controllability. Pain relief strongly depends on the perceived pain, but we found that it is less influenceable. Neither social nor self‐influence changed the magnitude of physiological pain‐relief responses. We conclude that pain relief is a basic mechanism not easily influenced by circumstantial manipulations.

Affective regulation through touch: homeostatic and allostatic mechanisms

We focus on social touch as a paradigmatic case of the embodied, cognitive, and metacognitive processes involved in social, affective regulation. Social touch appears to contribute three interrelated but distinct functions to affective regulation. First, it regulates affects by fulfilling embodied predictions about social proximity and attachment. Second, caregiving touch, such as warming an infant, regulates affect by socially enacting homeostatic control and co-regulation of physiological states. Third, affective touch such as gentle stroking or tickling regulates affect by allostatic regulation of the salience and epistemic gain of particular experiences in given contexts and timescales. These three functions of affective touch are most likely mediated, at least partly, by different neurobiological processes, including convergent hedonic, dopaminergic and analgesic, opioidergic pathways for the attachment function, 'calming' autonomic and endocrine pathways for the homeostatic function, while the allostatic function may be mediated by oxytocin release and related 'salience' neuromodulators and circuits.

Injustice Through Cultural Lens: A Pilot Qualitative Exploration of Pain-Related Injustice Appraisals Among Arab-Americans with Chronic Low Back Pain

The current qualitative study sought to obtain an in-depth understanding of how Arab-Americans conceptualize perceived injustice concerning their chronic low back pain (CLBP) by reflecting on the Injustice Experience Questionnaire (IEQ). Twelve Arab-American adults with CLBP were recruited from a metropolitan area in Alabama using a purposive sampling technique. Participants took part in individual, face-to-face, semi-structured interviews reflecting on each statement from the IEQ. Descriptive data analysis was generated for demographic and pain variables. Directed content analysis was conducted to identify themes and sub-themes. 'Blame and unfairness' and 'severity and irreparability of loss,' the 2 established theoretical factors comprising pain-related injustice appraisal were used as predominant themes. Acceptance emerged as an inductive theme with the following sub-themes: positive appraisal and resilience, attempts to reduce pain, religious values and fate, and belief that everything happening for a reason. The influence of religion was noted across all themes. The current pilot findings suggest that Arabic culture, heavily infused with Islamic beliefs, influences how Arab-Americans conceptualize pain-related injustice appraisals. Additional exploration of the cultural appropriateness of the IEQ among individuals of Arab background is needed to further elaborate on the subject of faith and religious belief suggested by the current study. Perspective: Although the study findings largely reflected established injustice literature constructs, several emergent themes regarding pain-related injustice appraisal were influenced by the participants' culture and religious beliefs. These findings may indicate that specific psychotherapeutic approaches that have been proven effective among some groups may not function similarly in other populations.

Getting in touch: A neural model of comforting touch

Comforting touch involves contact distress-alleviating behaviors of an observer towards the suffering of a target. A growing number of studies have investigated the effects of touch on pain attenuation, focusing on the (toucher), the target (comforted) or both. Here we synthesize findings of brain mechanisms underlying comforting touch in the target and toucher to propose an integrative brain model for understanding how touch attenuates distress. Building on evidence from the pain and distress literatures, our model applies interchangeably to pain and distress regulation. We describe comforting touch as a feedback-loop that begins with distress experienced by the target, triggering an empathic response in the toucher which in turn reduces distress in the target. This cycle is mediated by interactions between the neural circuits associated with touch perception, shared distress, emotion regulation and reward as well as brain-to-brain coupling in the observation-execution system. We conclude that formulating a model of comforting touch offers a mechanistic framework for understanding the effects of touch as well as other social interactions involving social support.

What is pain: Are cognitive and social features core components?

Pain is a universal experience, but it has been challenging to adequately define. The revised definition of pain recently published by the International Association for the Study of Pain addressed important shortcomings of the previous version; however, it remains narrow in its focus on sensory and emotional features of pain, failing to capture the substantial roles of cognitive and social core components of the experience and their importance to advances in pain management. This paper reviews evidence and theoretical models for the significant role social and cognitive factors play in pain experience and we argue that without explicit recognition of these core components in the definition, significant nuances are lost at a cost to understanding and clinical management of pain. A focus on sensory and emotional features perpetuates biomedical interventions and research, whereas recognition of cognitive and social features supports a multidimensional model of pain, advances in interdisciplinary care, and the benefits of cognitive behavioral therapy and self‐management interventions. We also explore the six Key Notes that accompany the new definition of pain, discuss their application to the understanding of pain in childhood, and, in doing so, further explore social and cognitive implications. Considerations are also described for assessment and treatment of pain in pediatric populations.