Psychological Considerations in the Assessment and Treatment of Pain in Neurorehabilitation and Psychological Factors Predictive of Therapeutic Response: Evidence and Recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation

Global Scientific Trends in Virtual Reality for Pain Treatment From 2000 to 2022: Bibliometric Analysis

Background

Virtual reality (VR) is a computer simulation technique that has been increasingly applied in pain management over the past 2 decades.

Objective

In this study, we used bibliometrics to explore the literature on VR and pain control, with the aim of identifying research progress and predicting future research hot spots.

Methods

We extracted literature on VR and pain control published between 2000 and 2022 from the Web of Science Core Collections and conducted bibliometric analyses. We analyzed the publication and citation trends in the past 2 decades, as well as publication and citation analyses of different countries, institutions, journals, and authors. For references, we conducted cocitation and burst analyses. For keywords, we conducted co-occurrence, clustering, timeline view, and citation burst analyses.

Results

Based on 1176 publications, we found that there was a continuous increase in publication and citation volumes, especially in the last 5 years. The United States was the most representative country, and the University of Washington was the most representative institution, with both having the most publications and citations. The most popular journal in this field was Burns, and Hoffman HG was the most productive author, leading many studies on patients with burn pain. The reference with the most citation burst was a study on the verification of new hardware in pain control. The keywords with the highest citation bursts related to various situations of pain such as "burn pain," "wound care," "low back pain," and "phantom limb."

Conclusions

VR has been applied in various clinical situations for pain management, among which burns and pediatric surgery have achieved satisfactory results. We infer that VR will be extended to more clinical pain situations in the future, such as pain control in wound care, low back pain, and phantom limb pain. New research hot spots will include the development of software and hardware to improve the immersive experience of VR for pain control. However, our work was based solely on English literature from the Web of Science database. For future studies, we recommend that researchers explore literature from multiple databases to enhance the scope of their research.

Breaking the cycle: unraveling the diagnostic, pathophysiological and treatment challenges of refractory migraine

Background

Refractory migraine is a poorly described complication of migraine in which migraine has chronified and become resistant to standard treatments. The true prevalence is unknown, but medication resistance is common in headache clinic patient populations. Given the lack of response to treatment, this patient population is extremely difficult to treat with limited guidance in the literature.

Objective

To review the diagnostic, pathophysiological, and management challenges in the refractory migraine population.

Discussion

There are no accepted, or even ICHD-3 appendix, diagnostic criteria for refractory migraine though several proposed criteria exist. Current proposed criteria often have low bars for refractoriness while also not meeting the needs of pediatrics, lower socioeconomic status, and developing nations. Pathophysiology is unknown but can be hypothesized as a persistent "on" state as a progression from chronic migraine with increasing central sensitization, but there may be heterogeneity in the underlying pathophysiology. No guidelines exist for treatment of refractory migraine; once all guideline-based treatments are tried, treatment consists of n-of-1 treatment trials paired with non-pharmacologic management.

Conclusion

Refractory migraine is poorly described diagnostically, its pathophysiology can only be guessed at by extension of chronic migraine, and treatment is more the art than science of medicine. Navigating care of this refractory population will require multidisciplinary care models and an emphasis on future research to answer these unknowns.

Factor Structure, Validity, and Reliability of the STarT Back Screening Tool in Italian Obese and Non-obese Patients With Low Back Pain

Background: The STarT Back Screening Tool (SBST) is a self-report questionnaire developed for prognostic purposes which evaluates risk factors for disability outcomes in patients with chronic low back pain. Previous studies found that its use enables to provide a cost-effective stratified care. However, its dimensionality has been assessed only using exploratory approaches, and reports on its psychometric properties are conflicting. Objective: The objective of this study was to assess the factorial structure and the psychometric properties of the Italian version of the STarT Back Screening Tool (SBST). Materials and Methods: Patients with medical diagnosis of low back pain were enrolled from a rehabilitation unit of a tertiary care hospital specialized in obesity care (Sample 1) and from a clinical internship center of an osteopathic training institute (Sample 2). At baseline and after 7 days patients were asked to fill a battery of self-report questionnaires. The factorial structure, internal consistency, test-retest reliability, and construct validity of the SBST were assessed. Results: One hundred forty-six patients were enrolled (62 from Sample 1 and 84 from Sample 2). The confirmatory factor analysis showed that the fit of the original two-correlated factors model was adequate (CFI = 0.98, TLI = 0.99, RMSEA = 0.03). Cronbach's α of the total scale (α = 0.64) and of the subscales (physical subscale α = 0.55; psychological subscale α = 0.61) was below the cutoffs, partly because of the low correlation of item 2 with the other items. Test-retest reliability was adequate (ICC = 0.84). The SBST had moderate correlations with comparisons questionnaires, except for the Roland-Morris Disability Questionnaire, which had a high correlation (r = 0.65). Discussion: The SBST has adequate psychometric properties and can be used to assess prognostic factors for disability in low back pain patients.

Neuropathic Pain in the Elderly

Neuropathic pain due to a lesion or a disease of the somatosensory system often affects older people presenting several comorbidities. Moreover, elderly patients are often poly-medicated, hospitalized and treated in a nursing home with a growing risk of drug interaction and recurrent hospitalization. Neuropathic pain in the elderly has to be managed by a multidimensional approach that involves several medical, social and psychological professionals in order to improve the quality of life of the patients and, where present, their relatives.

The Predictive Role of Executive Functions and Psychological Factors on Chronic Pain after Orthopaedic Surgery: A Longitudinal Cohort Study

Prevention and treatment of chronic post-surgical pain should be based on the early identification of patients at risk. The presence of a deficit in executive functions, along with the presence of psychological risk factors, could impair the use of appropriate pain coping strategies and might facilitate the transition to chronic post-surgical pain. A longitudinal cohort study was implemented. Patients listed for orthopaedic surgery were enrolled. Variables measured before surgery were pain intensity, the sensory, affective, cognitive and mixed components of pain, state and trait variables associated with the psychological status of the patient, fear of movement, pain catastrophizing, visual attention and cognitive flexibility. Pain intensity and the components of pain were re-evaluated after surgery and after three months. A linear mixed model was used to assess the predictors of pain intensity, and a multivariate linear mixed model was used to assess the predictors of the pain components. 167 patients were enrolled. Controlling for sex, age, pain duration and surgical procedure, catastrophizing and visual attention were predictors of pain intensity at follow-up. The sensory component of pain was predicted by state anxiety, healthcare-related fears, pain catastrophizing and visual attention. Anxiety and catastrophizing were predictors of the affective and evaluative components of pain. The mixed component of pain was predicted by state anxiety, healthcare-related fears and pain catastrophizing. Executive functions, along with psychological risk factors, shape the course of post-surgical pain. The efficacy of preventive and rehabilitation treatment could be possibly enhanced if these factors are treated.

Exploring Emotional Distress, Psychological Traits and Attitudes in Patients with Chronic Migraine Undergoing OnabotulinumtoxinA Prophylaxis versus Withdrawal Treatment

This explorative cross-sectional study aims at exploring emotional distress, psychological profiles, and the attitude towards receiving psychological support in eighty-seven patients with chronic migraine (CM) undergoing OnabotulinumtoxinA prophylactic treatment (OBT-A, n = 40) or withdrawal treatment (WT, n = 47). The outcomes were explored through a specific battery of questionnaires. 25% of patients undergoing OBT-A and almost half of the patients undergoing WT reported psychological distress of at least moderate-severe level, respectively. Coping strategies, self-efficacy, and perceived social support were similar in the two groups. Patients undergoing OBT-A presented lower psychological inflexibility than patients undergoing WT. Predictors of higher psychological distress were low perceived social support by friends, low self-efficacy, and higher avoidance strategies. In both groups, most of the patients evaluated receiving psychological support to be useful (79%). The potential beneficial effects of OBT-A on the severity of symptoms and psychological distress might further support its role in the multidisciplinary management of patients with CM. Identifying patients with psychological vulnerabilities who may benefit from psychological support is relevant in patients with CM.

Clinical perspective on pain in multiple sclerosis

Pain is an important and frequent symptom in multiple sclerosis (MS), which leads to a low quality of life, increased disability level, and lack of employment and mental health. Recently, studies have shown increased interest in pain in MS and there is a growing evidence of its prevalence. However, the literature suffers from lack of experimental studies focusing on pain reduction. This topical review summarizes the current knowledge about pain in MS with its definitions, assessments, treatments and rehabilitation within a holistic perspective.

Is There an Association Between Migraine and Major Depressive Disorder? A Narrative Review

Various studies on the association of migraine with depression are published. The comorbidity may upgrade health conditions up to a critical degree. Besides, the duration of symptoms and treatment may be prolonged. Moreover, these conditions can force substantial financial and social hardships on patients and their families. In this literature review, we intend to examine the evidence obtained on the possible associations between migraine and major depressive disorder (MDD). This review is focused on aminergic neurons. One of the variables associated with patients who experience both of these two diseases might have a history of assault. In migraine and MDD patients, genetic evidence, such as single nucleotide polymorphisms (SNP), was found to be one of the associations. Another theory concluded that actual headache diagnosed in patients who received no treatment manifests a history of anxiety, and later, the patients display severe somatic symptoms. In conclusion, there is a robust molecular genetic background, explaining the relationship between migraines and MDD. This correlated data renders a combination of both diagnoses as single separate entities. However, further studies are encouraged to point out the issue of treatment strategies.

Quality of life, pain, and psychological factors in patients undergoing surgery for primary tumors of the spine

PURPOSE

Knowledge about quality of life (QOL), pain, and psychological factors in patients with primary tumors of the spine is limited, but is important in planning rehabilitation after surgery. Aims of this study were to assess the preoperative levels and improvement after surgery of these factors, and to identify the predictors of postoperative pain and QOL.

METHODS

Patients with primary tumors undergoing spine surgery were matched for sex and age with patients with metastatic tumors. QOL was measured at baseline and three months after surgery with the physical (PCS) and mental (MCS) components SF-12 subscales, pain intensity with a numeric rating scale (NRS), depression with the Beck Depression Inventory (BDI). Preoperative SF-12, NRS, and BDI levels and differences in follow-up improvement in SF-12 and NRS were compared across samples. LASSO regressions were performed to find predictors of follow-up SF-12 and NRS.

RESULTS

Patients with primary tumors showed better PCS and NRS, and similar BDI and MCS than patients with metastatic tumors. At follow-up, they showed stronger improvement in the MCS and no improvement in the PCS. All QOL scores were below those of the general population. Follow-up PCS was predicted by baseline PCS and BDI; MCS by baseline MCS; pain intensity by baseline pain intensity and BDI.

CONCLUSION

Patients with primary tumors of the spine suffer from moderate levels of physical and mental impairment. Depression influences surgical outcomes.

[Psychogenic pain]

Psychogenic pain is one of the urgent problems of medicine. To date, pathogenetic mechanisms of development of pain syndrome are unclear, there is no uniform classification. Pain, developing in patients with a mental disorder without an organic damage to the nervous system, and pain, which is a complication of an already existing pain syndrome of neuropathic or nociceptive nature, should be considered separately. Treatment of psychogenic pain syndromes should be integrated with the mandatory use of methods aimed at modifying the patient's lifestyle and attitude towards the illness.

A systematic review of structural and functional MRI studies on pain catastrophizing

Objectives: Pain catastrophizing is reliably associated with pain reports during experimental pain in healthy, pain-free subjects and in people with chronic pain. It also correlates with self-reports of clinical pain intensity/severity in a variety of disorders characterized by chronic pain in adults, adolescents and children. However, processes, through which it exerts its effects are yet unclear. In this paper, our primary aim was to synthesize neuroimaging research to open a window to possible mechanisms underlying pain catastrophizing in both chronic pain patients and healthy controls. We also aimed to compare whether the neural correlates of pain catastrophizing are similar in these two groups.

Methods: PubMed and the Web of Science were searched for magnetic resonance imaging (MRI) studies that explored neural correlates of pain catastrophizing.

Results: Twenty articles met the inclusion criteria. The results of our review show a connection between pain catastrophizing and brain areas tightly connected to pain perception (including the somatosensory cortices, anterior insula, anterior cingulate cortex and thalamus) and/or modulation (eg, the dorsolateral prefrontal cortex). Our results also highlight that these processes - in relation to pain catastrophizing - are more pronounced in chronic pain patients, suggesting that structural and functional brain alterations (and perhaps mechanisms) related to pain catastrophizing may depend on prior and/or relatively stable/constant pain experience. However, we also found methodological issues and differences that could lead to divergent results.

Discussion: Based on our results, pain catastrophizing might be related to salience detection, pain processing, and top-down attentional processes. More research is recommended to explore neural changes to specific types of catastrophizing thoughts (eg, experimentally induced and/or state). Furthermore, we provide ideas regarding pain catastrophizing studies in the future for a more standardized approach.

Pain in relation to emotion regulatory resources and self-compassion: a non-randomized correlational study involving recollected early childhood experiences and insecure attachment

Background

Pain is common in most diseases and is usually treated by medical and physical approaches (medications, exercise). Limited attention has been given to whether non-medical approaches (such as emotion regulation abilities including self-compassion) can help further reduce the pain experienced. Scleroderma (systemic sclerosis), a painful and complex autoimmune connective tissue and vascular disease, was examined in this study in relation to psychological aspects of pain and the links of pain to (1) early life experiences, (2) current insecure attachment style, (3) physiological arousal (negative, hyper-arousal), and (4) personal emotion regulation (self-compassion). Knowledge about these relationships may help in the treatment of pain.

Participants and procedure

Participants (120) from Australia (39) and the United Kingdom (81) completed an online or a hard copy survey; 78 participants remained for analysis after screening.

Results

We found that poor or limited positive early life experiences and a current insecure (dismissive) attachment style contributed significantly to experiencing elevated levels of pain. We also found that negative early life experiences and limited emotion regulation (low self-compassion) predicted hyper-arousal, which in turn was associated with experienced pain. Insecure dismissive attachment style and hyper-arousal were significantly correlated.

Conclusions

These findings suggest that negative childhood experiences and an insecure dismissive attachment style may determine how emotional experiences are regulated or managed by individuals in disease-related pain. Implications include that interventions addressing attachment style and self-compassion may help reduce pain in the individuals concerned, thus helping supplement the effectiveness of current medication and physical approaches.

Multiple Factors Drive Opioid Prescribing at the Time of Discharge

Multiple factors potentially influence pain intensity or frequency, and consequently the need for an opioid prescription. This study aims to identify factors associated with being discharged with an outpatient opioid prescription. We constructed a database containing clinical, non-clinical, and organizational variables from the EHR that are potentially relevant for ordering an opioid at discharge. Descriptive statistics of these variables and univariate association analysis reveal that all of the examined variables to be statistically significantly associated with opioid prescription at discharge. Further, we fitted a random forest model to examine the information content in the examined variables regarding whether a patient will be discharged with an opioid. The model resulted in a mean AUC of 0.84, suggesting the factors examined in this study in combination contain significant information regarding prescription of an opioid at discharge.

What Is the Role of the Placebo Effect for Pain Relief in Neurorehabilitation? Clinical Implications From the Italian Consensus Conference on Pain in Neurorehabilitation

Background

It is increasingly acknowledged that the outcomes of medical treatments are influenced by the context of the clinical encounter through the mechanisms of the placebo effect. The phenomenon of placebo analgesia might be exploited to maximize the efficacy of neurorehabilitation treatments. Since its intensity varies across neurological disorders, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCP) summarized the studies on this field to provide guidance on its use.

Methods

A review of the existing reviews and meta-analyses was performed to assess the magnitude of the placebo effect in disorders that may undergo neurorehabilitation treatment. The search was performed on Pubmed using placebo, pain, and the names of neurological disorders as keywords. Methodological quality was assessed using a pre-existing checklist. Data about the magnitude of the placebo effect were extracted from the included reviews and were commented in a narrative form.

Results

11 articles were included in this review. Placebo treatments showed weak effects in central neuropathic pain (pain reduction from 0.44 to 0.66 on a 0-10 scale) and moderate effects in postherpetic neuralgia (1.16), in diabetic peripheral neuropathy (1.45), and in pain associated to HIV (1.82). Moderate effects were also found on pain due to fibromyalgia and migraine; only weak short-term effects were found in complex regional pain syndrome. Confounding variables might have influenced these results.

Clinical implications

These estimates should be interpreted with caution, but underscore that the placebo effect can be exploited in neurorehabilitation programs. It is not necessary to conceal its use from the patient. Knowledge of placebo mechanisms can be used to shape the doctor-patient relationship, to reduce the use of analgesic drugs and to train the patient to become an active agent of the therapy.

Changes in Pain Perception following Psychotherapy: The Mediating Role of Psychological Components

Chronic pain is frequently associated with significant psychological issues, such as depression or anxiety. Psychological treatments, such as psychotherapy, can often alleviate both psychological and pain symptoms. However, there is limited research about the association between psychological symptoms and perceived pain in the context of psychotherapeutic interventions. We conducted a retrospective study that analyzed, in a hospital context, how changes in psychological functioning and well-being were associated with pain reduction. Thirty-seven records of patients with chronic pain attending psychotherapy in a public hospital were included. All patients were assessed before psychotherapy, as well as after 6 and 10 months, with self-reported questionnaires about pain, anxiety, depression, and psychological functioning. Results indicate that reductions in anxiety, depression, psychological problems, risk factors, and well-being are strongly related with a reduction in pain, further confirming the hypothesis that psychological morbidity is associated with pain severity.

Alexithymia and Depression Affect Quality of Life in Patients With Chronic Pain: A Study on 205 Patients With Fibromyalgia

Pain in fibromyalgia (FM) is accompanied by a heterogeneous series of other symptoms, which strongly affect patients’ quality of life and interfere with social and work performance. The present study aimed to evaluate the effects of alexithymia on both the physical and the psychosocial components of the health-related quality of life (HRQoL) of FM patients, controlling for the concomitant effects of depression, anxiety, and pain. In particular, given the strong interconnection between depression and alexithymia, the relationship between alexithymia and HRQoL as mediated by depressive symptoms was further investigated. Data were collected on a consecutive sample of 205 female patients with a main diagnosis of FM. The results showed that about 26% of the patients showed the presence of alexithymia, as assessed by the Toronto Alexithymia Scale (TAS-20). Clinically relevant levels of depressive and anxiety symptoms were present in 61 and 60% of the patients, respectively. The results of the hierarchical multiple regression analyses showed that pain intensity (PI) and depressive symptoms explained the 45% of the variance of the physical component of HRQoL (p < 0.001). Regarding the mental component of HRQoL, depressive and anxiety symptoms, alexithymia, and PI significantly explained 61% of the variance (p < 0.001). The mediation analyses confirmed that alexithymia had a direct effect on the mental component of HRQoL and showed a statistically significant indirect effect on both the physical and the mental components, through the mediation of depressive symptoms. In conclusion, the results of the present study suggested the presence of both a direct and an indirect effect of alexithymia, in particular of the difficulty identifying feeling, on the HRQoL of patients with FM. Indeed, even though the concomitant presence of depressive symptoms is responsible of an indirect effect, alexithymia per se seems to directly contribute to worsen the impact that this chronic pain pathology has on the patients’ quality of life, especially regarding the psychosocial functioning.

Shared mechanisms of epilepsy, migraine and affective disorders

Since the nineteenth century several clinical features have been observed in common between migraine and epilepsy (such as episodic attacks, triggering factors, presence of aura, frequent familiarity), but only in recent years researchers have really engaged in finding a common pathogenic mechanism. From studies of disease incidence, we understand how either migraine among patients with epilepsy or epilepsy among migraine patients are more frequent than in the general population. This association may result from a direct causality, by the same environmental risk factors and/or by a common genetic susceptibility. Ischemic events are the most frequent direct causes, especially among women and elderly people: migraine can lead to silent or clinically considerable strokes, and these ones could explain the increased risk of developing epilepsy in people with a history of migraine. Head injuries can lead headache, often with migraine characteristics, and seizures. But there are also many idiopathic cases. The comorbidity migraine-epilepsy might be explained in these cases by a neuronal hyperexcitability, which increases the risk of both diseases: a higher concentration of extracellular glutamate, the main excitatory neurotransmitter, leads in fact as a result a Cortical Spreading Depression (the pathophysiological mechanism at the base of aura) and convulsions; antiepileptic drugs such as topiramate are, therefore, used also in migraine prophylaxis. A genetic link between these two diseases is particularly evident in familial hemiplegic migraine: mutations of ATP1A2, SCN1A and CACNA1A genes, identified in this disease, have also been involved in different types of epilepsy and febrile seizures. The channelopathies, especially engaging sodium and potassium ions, can be the common pathogenic mechanism of migraine and epilepsy. Both migraine and epilepsy also have, compared to the general population, a higher prevalence and incidence of affective disorders such as anxiety, depression and suicidal ideation. Anxiety and depression can be part of symptoms that accompany migraine or seizures. Female patients with a long history of illness and frequent attacks are the most at risk. The impact of these diseases on the quality of life is the most obvious cause of these disorders, furthermore some antiepileptic drugs can have depressive effects on mood; the anxious-depressive disorders often result from the interaction between iatrogenic and psychosocial factor with common neurobiological pathogenesis. A chronic lowering of 5-HT (serotonin) levels has been demonstrated both in migraineurs and in depressed patients; amitriptyline and venlafaxine are the most indicated drugs in the treatment of migraine with comorbid depression currently. Likewise imbalance in dopamine levels has been also demonstrated: a D2 receptor genotype has been directly related to comorbidity migraine-depression. In women, hormonal fluctuations are also crucial, especially in the post-partum and late luteal phase, when the estrogenic reduction, associated with up-regulation of SNPs and down-regulation of serotonergic and GABAergic systems, increases the risk of migraine and depression. Furthermore, central sensitization phenomena have been highlighted in both diseases, and result in a progressive increase in the frequency of attacks up to chronicity and the consequent development of drug resistance and overuse. Further studies will be necessary to deepen the close relationship between these three diseases.

A Review of the Emotional Aspects of Neuropathic Pain: From Comorbidity to Co-Pathogenesis

Neuropathic pain is characterized by both sensory and affective disturbances, supporting the notion that pain and mood disorders share common pathogenetic mechanisms. Moreover, biological and neuroimaging data show that common brain areas are involved in the modulation of painful and emotional experiences. Improved understanding of the molecular mechanisms underlying the role of neuroinflammation in regulation of affective behavior in neuropathic pain states is important for the development of novel therapeutic strategies. Psychological issues must be considered a factor influencing treatment and outcome in patients with neuropathic pain.

Funding: Pfizer, Italy.

Assessing and treating primary headaches and cranio-facial pain in patients undergoing rehabilitation for neurological diseases

BACKGROUND

Pain is a very common condition in patient undergoing rehabilitation for neurological disease; however the presence of primary headaches and other cranio-facial pains, particularly when they are actually or apparently independent from the disability for which patient is undergoing rehabilitation, is often neglected. Diagnostic and therapeutic international and national guidelines, as well as tools for the subjective measure of head pain are available and should also be applied in the neurorehabilitation setting. This calls for searching the presence of head pain, independently from the rehabilitation needs, since pain, either episodic or chronic, interferes with patient performance by affecting physical and emotional status. Pain may also interfere with sleep and therefore hamper recovery.

METHODS

In our role of task force of the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN), we have elaborated specific recommendations for diagnosing and treating head pains in patients undergoing rehabilitation for neurological diseases.

RESULTS AND CONCLUSION

In this narrative review, we describe the available literature that has been evaluated in order to define the recommendations and outline the needs of epidemiological studies concerning headache and other cranio-facial pain in neurorehabilitation.

Differences in Multidisciplinary and Interdisciplinary Treatment Programs for Fibromyalgia: A Mapping Review

Fibromyalgia is a multifaceted chronic pain syndrome and the integration of different health disciplines is strongly recommended for its care. The interventions based on this principle are very heterogeneous and the difference across their structures has not been extensively studied, leading to incorrect conclusions when their outcomes are pooled. The objective of this mapping review was to summarize the characteristics of these programs, with particular focus on the integration of their components. We performed a search of the literature about treatments for fibromyalgia involving multiple disciplines on PubMed and Scopus. Starting from 560 articles, we included 22 noncontrolled studies, 10 controlled studies, and 17 RCTs evaluating the effects of 38 multidisciplinary or interdisciplinary interventions. The average quality of the studies was low. Their outcomes were usually pain intensity, quality of life, and psychological variables. We created a map of the programs based on the degree of integration of the included disciplines, which ranged from a juxtaposition of few components to a complex harmonization of different perspectives obtained through teamwork strategies. The rehabilitation programs were then thoroughly described with regard to the duration, setting, therapeutic components, and professionals included. The implications for future quantitative reviews are discussed.

Attachment Style and Chronic Pain: Toward an Interpersonal Model of Pain

Chronic pain (CP) is a burdensome symptom. Different psychological models have been proposed to explain the role of psychological and social factors in developing and maintaining CP. Attachment, for example, is a psychological construct of possible relevance in CP. The first studies on the role of attachment in CP did not investigate the partner’s psychological factors, thus neglecting the influence of the latter. The main aim of this mini-review was to examine the more recent literature investigating the relationship between CP and attachment style. In particular, whether or not more recent studies assessed the psychological variables of a patient’s partner. The articles were selected from the Medline/PubMed database using the search terms “attachment” AND “pain”; “CP” AND “attachment style,” which led to nine papers being identified. The results showed that, even though the key point was still the hypothesis that an insecure attachment style is associated with CP, in recent years researchers have focused on the possible psychological aspects mediating between attachment style and CP. In particular, worrying, coping strategies, catastrophizing and perceived spouse responses to pain behavior were taken into account. Only one study considered the role of the reciprocal influence of attachment style of both patient and partner, underlining the role of real significant others’ responses to pain behaviors. In conclusion, the results of the present mini-review highlight how in recent years researchers have moved toward investigating those psychological aspects that could mediate the relationship between attachment and CP, while only partially evaluating the interpersonal perspective.