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Göller PJ, Reicherts P, Lautenbacher S, Kunz M. Vicarious facilitation of facial responses to pain. Eur J Pain 2024; 28:133-143. [PMID: 37592377 DOI: 10.1002/ejp.2169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/10/2023] [Accepted: 08/01/2023] [Indexed: 08/19/2023]
Abstract
INTRODUCTION Observing facial expressions of pain has been shown to lead to increased subjective, neural and autonomic pain responses. Surprisingly, these vicarious facilitation effects on its corresponding response channel, namely facial responses to pain have mostly been neglected. We aim to examine whether the prior exposure to facial expressions of pain leads to a facilitation of facial responses to experimental pain; and whether this facilitation is linked to the valence (pain vs. neutral expression) or also linked to specific motor-features of the facial pain expressions (different facial muscle movements). METHOD Subjective (intensity and unpleasantness ratings) and facial responses (Facial Action Coding System) of 64 participants (34 female) to painful and non-painful heat stimuli were assessed. Before each heat stimulus, video clips of computer-generated facial expressions (three different pain expressions and a neutral expression) were presented. RESULTS The prior exposure to facial expressions of pain led to increased subjective and facial responses to pain. Further, vicarious pain facilitation of facial responses was significantly correlated with facilitation of unpleasantness ratings. We also found evidence that this vicarious facilitation of facial responses was not only linked to the presentation of pain versus neutral expressions but also to specific motor-features of the pain cue (increase in congruent facial muscle movements). DISCUSSION Vicarious pain facilitation was found for subjective and facial responses to pain. The results are discussed with reference to the motivational priming hypothesis as well as with reference to motor priming. SIGNIFICANCE Our study uncovers evidence that facial pain responses are not only influenced by motivational priming (similar to other types of pain responses), but also by motor-priming. These findings shed light on the complexity - ranging from social, affective and motor mechanisms - underling vicarious facilitation of pain.
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Affiliation(s)
- Peter J Göller
- Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
- Bamberger LivingLab Dementia (BamLiD), University of Bamberg, Bamberg, Germany
| | - Philipp Reicherts
- Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Stefan Lautenbacher
- Bamberger LivingLab Dementia (BamLiD), University of Bamberg, Bamberg, Germany
| | - Miriam Kunz
- Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
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Zillig AL, Pauli P, Wieser M, Reicherts P. Better safe than sorry?-On the influence of learned safety on pain perception. PLoS One 2023; 18:e0289047. [PMID: 37934741 PMCID: PMC10629634 DOI: 10.1371/journal.pone.0289047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 07/10/2023] [Indexed: 11/09/2023] Open
Abstract
The experience of threat was found to result-mostly-in increased pain, however it is still unclear whether the exact opposite, namely the feeling of safety may lead to a reduction of pain. To test this hypothesis, we conducted two between-subject experiments (N = 94; N = 87), investigating whether learned safety relative to a neutral control condition can reduce pain, while threat should lead to increased pain compared to a neutral condition. Therefore, participants first underwent either threat or safety conditioning, before entering an identical test phase, where the previously conditioned threat or safety cue and a newly introduced visual cue were presented simultaneously with heat pain stimuli. Methodological changes were performed in experiment 2 to prevent safety extinction and to facilitate conditioning in the first place: We included additional verbal instructions, increased the maximum length of the ISI and raised CS-US contingency in the threat group from 50% to 75%. In addition to pain ratings and ratings of the visual cues (threat, safety, arousal, valence, and contingency), in both experiments, we collected heart rate and skin conductance. Analysis of the cue ratings during acquisition indicate successful threat and safety induction, however results of the test phase, when also heat pain was administered, demonstrate rapid safety extinction in both experiments. Results suggest rather small modulation of subjective and physiological pain responses following threat or safety cues relative to the neutral condition. However, exploratory analysis revealed reduced pain ratings in later trials of the experiment in the safety group compared to the threat group in both studies, suggesting different temporal dynamics for threat and safety learning and extinction, respectively. Perspective: The present results demonstrate the challenge to maintain safety in the presence of acute pain and suggest more research on the interaction of affective learning mechanism and pain processing.
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Affiliation(s)
- Anna-Lena Zillig
- Department of Psychology, University of Würzburg, Würzburg, Germany
| | - Paul Pauli
- Department of Psychology, University of Würzburg, Würzburg, Germany
| | - Matthias Wieser
- Department of Clinical Psychology, Erasmus University of Rotterdam, Rotterdam, Netherlands
| | - Philipp Reicherts
- Department of Medical Psychology and Sociology, University of Augsburg, Augsburg, Germany
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Zerbini G, Göller PJ, Lembke K, Kunz M, Reicherts P. Relationship between chronotype and pain threshold in a sample of young healthy adults. Pain Rep 2023; 8:e1085. [PMID: 37358936 PMCID: PMC10287117 DOI: 10.1097/pr9.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/15/2023] [Accepted: 04/29/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction Chronotype indicates the biological preference for timing of activity and sleep. Being a late chronotype (ie, having a tendency for late sleep times) is associated with several mental and physical health problems. Previous studies found that late chronotypes are also more susceptible to chronic pain, but the relationship between chronotype and pain sensitivity remains unclear. Objectives The aim of this study was to investigate the relationship between chronotype and heat pain threshold (as an indicator of pain sensitivity) in a sample of young healthy adults. Methods We analyzed data from 316 young healthy adults participating in 4 different studies run at the Medical Faculty of the University of Augsburg. In all studies, chronotype and other sleep variables (eg, sleep duration) were assessed using the micro Munich ChronoType Questionnaire. Heat pain threshold was assessed with the method of adjustment. Results Chronotype was not significantly associated with the heat pain threshold. Entering the other sleep variables in separate regression models did also not significantly explain variance in heat pain threshold. Conclusion Our null findings are in contrast with previous notions that late chronotypes might be more sensitive to pain and more susceptible to chronic pain. Given the scarcity of the literature on this topic, more studies are needed to clarify the relationship between chronotype and pain sensitivity in different age populations, while also considering distinct pain modalities or other types of pain tests.
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Affiliation(s)
- Giulia Zerbini
- Corresponding author. Address: Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany. Tel.: +49(0)8215983620. E-mail address: (G. Zerbini)
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Halms T, Strasser M, Papazova I, Reicherts P, Zerbini G, Grundey S, Täumer E, Ohmer-Kluge M, Kunz M, Hasan A. What do healthcare workers need? A qualitative study on support strategies to protect mental health of healthcare workers during the SARS-CoV-2 pandemic. BMC Psychiatry 2023; 23:195. [PMID: 36964558 PMCID: PMC10038365 DOI: 10.1186/s12888-023-04686-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/15/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND To support healthcare workers (HCWs) during the increased burden caused by the SARS-CoV-2 pandemic, numerous recommendations for action and possible interventions have been developed. However, the actual protective factors, needs and desires of those affected, as well as potential barriers to implementing psychological interventions, have been insufficiently examined. This study addresses this research gap and captures HCWs' experiences and views. METHODS Medical personnel including nursing staff and physicians were recruited for a qualitative study regarding protective factors as well as barriers to the implementation of support services. We conducted 21 individual, semi-structured interviews with members of the medical staff at tertiary care center in Germany. The collected data were analyzed using a qualitative content analysis. RESULTS The analyses showed that social interaction in the professional and private context was rated as helpful in coping with the challenges of everyday work amplified by the SARS-CoV-2 pandemic. The results also suggest that the available support services, despite being highly valued, were rarely accessed. Possible barriers included the fear of negative consequences when asking for support. It could be deduced that the fear and shame of admitting one's own mistakes as well as the work-related tradition of showing no weakness could be the underlying factors for this fear. RESULTS The results of this study suggest that medical staff need a more extensive range of low-threshold support services, which should be adapted to the respective needs of the professional groups. The study also provides indications that the norms and expectations represented in the hospital system require critical reflection.
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Affiliation(s)
- Theresa Halms
- Department of Psychiatry and Psychotherapy, Medical Faculty, University of Augsburg, Bezirkskrankenhaus, Augsburg, Germany.
| | - Martina Strasser
- Department of Psychiatry and Psychotherapy, Medical Faculty, University of Augsburg, Bezirkskrankenhaus, Augsburg, Germany
| | - Irina Papazova
- Department of Psychiatry and Psychotherapy, Medical Faculty, University of Augsburg, Bezirkskrankenhaus, Augsburg, Germany
| | - Philipp Reicherts
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Giulia Zerbini
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | | | - Esther Täumer
- Department of Psychiatry and Psychotherapy, University Hospital, Klinikum der Universität München, Ludwig-Maximilians University Munich, Munich, Germany
| | | | - Miriam Kunz
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, Medical Faculty, University of Augsburg, Bezirkskrankenhaus, Augsburg, Germany
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Göller PJ, Reicherts P, Lautenbacher S, Kunz M. How gender affects the decoding of facial expressions of pain. Scand J Pain 2022; 23:372-381. [PMID: 36220060 DOI: 10.1515/sjpain-2022-0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/19/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Gender has been suggested to play a critical role in how facial expressions of pain are perceived by others. With the present study we aim to further investigate how gender might impact the decoding of facial expressions of pain, (i) by varying both the gender of the observer as well as the gender of the expressor and (ii) by considering two different aspects of the decoding process, namely intensity decoding and pain recognition. METHODS In two online-studies, videos of facial expressions of pain as well as of anger and disgust displayed by male and female avatars were presented to male and female participants. In the first study, valence and arousal ratings were assessed (intensity decoding) and in the second study, participants provided intensity ratings for different affective states, that allowed for assessing intensity decoding as well as pain recognition. RESULTS The gender of the avatar significantly affected the intensity decoding of facial expressions of pain, with higher ratings (arousal, valence, pain intensity) for female compared to male avatars. In contrast, the gender of the observer had no significant impact on intensity decoding. With regard to pain recognition (differentiating pain from anger and disgust), neither the gender of the avatar, nor the gender of the observer had any affect. CONCLUSIONS Only the gender of the expressor seems to have a substantial impact on the decoding of facial expressions of pain, whereas the gender of the observer seems of less relevance. Reasons for the tendency to see more pain in female faces might be due to psychosocial factors (e.g., gender stereotypes) and require further research.
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Affiliation(s)
- Peter J Göller
- Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
- Physiological Psychology, University of Bamberg, Bamberg, Germany
| | - Philipp Reicherts
- Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | | | - Miriam Kunz
- Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
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Reicherts P, Zerbini G, Halms T, Strasser M, Papazova I, Hasan A, Kunz M. COVID-19 related psychological burden and potential benefits of vaccination - Data from a repeated cross-sectional survey in healthcare workers. Psychiatry Research Communications 2022; 2:100054. [PMID: 35702354 PMCID: PMC9181270 DOI: 10.1016/j.psycom.2022.100054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/13/2022] [Accepted: 06/05/2022] [Indexed: 11/27/2022]
Abstract
The COVID-19 pandemic is impacting the psychological well-being, especially of health care workers, for more than two years now. Here, we followed-up on a survey we conducted at the very beginning of the pandemic, to determine potential changes in psychological strain experienced by health care workers one year later. Since our first survey in 2020, COVID-19 vaccines have been established, thus we assessed whether vaccination-status might modulate psychological burden of health care workers. We also collected data on resilience and sleep, as those might be related to successful coping. Between March and April 2021, nurses and physicians (N = 286) working at the University Hospital Augsburg - with high or low exposure to COVID-19 patients - took part in an online survey. We found that fully vaccinated personnel reported lower levels of anxiety, depression, stress and exhaustion suggesting the potential positive consequences of vaccination beyond the obvious protection against a COVID-19 infection. Nurses reported more depressive symptoms, anxiety, stress and exhaustion and lower levels of job fulfilment than physicians. Individuals with high exposure to COVID-19 patients reported higher exhaustion and depersonalization. Resilience and sleep quality were significantly correlated with psychological and work-related burden, suggesting their potential role as protective resources. In general, the comparison of the present data to the survey conducted in 2020 suggests an overall increase of psychological burden in health care workers. Despite these surely alarming findings, it should be noted that being vaccinated might come along with reduced psychological strain.
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Affiliation(s)
- P Reicherts
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Germany
| | - G Zerbini
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Germany
| | - T Halms
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, Bezirkskrankenhaus, Augsburg, Germany
| | - M Strasser
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, Bezirkskrankenhaus, Augsburg, Germany
| | - I Papazova
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, Bezirkskrankenhaus, Augsburg, Germany
| | - A Hasan
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, Bezirkskrankenhaus, Augsburg, Germany
| | - M Kunz
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Germany
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Schneider SK, Pauli P, Lautenbacher S, Reicherts P. Effects of psychosocial stress and performance feedback on pain processing and its correlation with subjective and neuroendocrine parameters. Scand J Pain 2022; 23:389-401. [PMID: 35938978 DOI: 10.1515/sjpain-2021-0204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 06/28/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Previous research on stress-induced pain modulation suggests that moderate psychological stress usually leads to hyperalgesia while more severe threat results in hypoalgesia. However, existing studies often lack suitable control conditions imperative to identify mere stress effects. Similarly, research mainly focused on pure anticipation of a social threat, not taking into consideration actual experiences of social evaluation. Therefore, we set out to investigate actual social up- and downgrading combined with a standardized stress paradigm to evaluate short-term and prolonged changes in pain perception and their potential association with neuroendocrine and subjective stress parameters. METHODS We allocated 177 healthy women to four experimental conditions, either the standard version of the Trier Social Stress Test (TSST) followed by positive, negative or no performance feedback, or a well-matched but less demanding placebo version of the TSST. Stress responses were assessed with ratings, salivary alpha-amylase, and salivary cortisol. To capture putative effects of stress on pain, heat pain threshold, ratings of phasic heat pain stimuli, and conditioned pain modulation were measured. RESULTS Despite a largely successful stress induction, results do not support a reliable influence of experimentally induced social stress-with or without subsequent performance feedback-on pain in women. Further, we found no clear association of pain modulation and changes in neuroendocrine or subjective stress responses. CONCLUSIONS Our results contrast previous studies, which repeatedly demonstrated stress-induced hypo- or hyperalgesia. This might be due to methodological reasons as former research was often characterized by high heterogeneity regarding the applied stressors, low sample sizes, and lacking or inconclusive control conditions. Thus, our results raise the question whether pain modulation in women by experimental psychosocial stress might have been overestimated in the past. Future research is necessary, which should employ parametric stress induction methods including well-matched control tasks, taking into consideration the participants' gender/sex and the time course of the stress response relative to pain assessment. The study is registered as DRKS00026946 at 'Deutsches Register Klinischer Studien' (DRKS) and can be also found at the World Health Organization's search portal.
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Affiliation(s)
- Sarah Karen Schneider
- Department of Psychology (Biological Psychology, Clinical Psychology and Psychotherapy), University of Würzburg, Würzburg, Germany
| | - Paul Pauli
- Department of Psychology (Biological Psychology, Clinical Psychology and Psychotherapy), University of Würzburg, Würzburg, Germany.,Centre of Mental Health, University Hospital of Würzburg, University of Würzburg, Würzburg, Germany
| | - Stefan Lautenbacher
- Department of Physiological Psychology, Institute of Psychology, University of Bamberg, Bamberg, Germany
| | - Philipp Reicherts
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
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Zerbini G, Taflinger S, Reicherts P, Kunz M, Sattler S. Perceived risk of COVID-19 exposure and poor COVID-19 prognosis impair sleep: The mediating and moderating roles of COVID-19-related anxiety and knowledge. J Sleep Res 2022; 31:e13569. [PMID: 35238104 PMCID: PMC9115167 DOI: 10.1111/jsr.13569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 01/26/2023]
Abstract
The ongoing COVID‐19 pandemic has been linked to increased levels of stress, depression, and anxiety in many people around the world. Therefore, identifying individuals at risk of psychosocial burden during this unprecedented crisis is essential for developing prevention measures and treatment options for mental health issues. To this aim, we investigated two risk groups: individuals at higher risk of exposure to the virus and individuals at higher risk of poor prognosis if they contract the virus. We conducted a survey (N = 4167) with a representative sample of the German population and assessed perceived risk of COVID‐19 exposure and poor prognosis if infected, COVID‐19‐related anxiety, problems with sleep and daytime functioning, as well as self‐reported knowledge about the disease. Results showed that perceived risk group membership was linked to increased problems with sleep and daytime functioning via elevated levels of COVID‐19‐related anxiety. This mediated effect was further moderated by self‐reported COVID‐19 knowledge, but only for individuals who rated themselves at higher risk of COVID‐19 exposure. Thus, knowledge buffered the negative effect of exposure risk on anxiety and ultimately on sleep in this risk group. Reaching individuals at increased risk of exposure with clear information about the disease, how to prevent infection, and treatment options could be an effective strategy to contain anxiety levels and promote good sleep, which is important for general well‐being.
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Affiliation(s)
- Giulia Zerbini
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Shannon Taflinger
- Institute of Sociology and Social Psychology, University of Cologne, Cologne, Germany
| | - Philipp Reicherts
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Miriam Kunz
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Sebastian Sattler
- Institute of Sociology and Social Psychology, University of Cologne, Cologne, Germany.,Faculty of Sociology, Bielefeld University, Bielefeld, Germany.,Pragmatic Health Ethics Research Unit, Institut de Recherches Cliniques de Montréal, Montréal, Germany
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König T, Reicherts P, Leha A, Hrasky V, Wiegand A. Retrospective study on risk factors for repeated dental treatment of children under general anaesthesia. Eur J Paediatr Dent 2020; 21:183-186. [PMID: 32893648 DOI: 10.23804/ejpd.2020.21.03.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIM This retrospective study aimed to evaluate potential risk factors predicting repeated dental treatment of children under general anaesthesia. MATERIALS AND METHODS Children below 12 years of age receiving at least one dental treatment under general anaesthesia between 03/2010 and 10/2018 were analysed (n = 935, mean age: 4.6 ± 2.4). Dental records were analysed retrospectively for anamnestic, demographic, oral health and treatment factors. Kaplan-Meier statistics was used to estimate the time to second dental treatment under general anaesthesia. Potential risk factors for repeated dental treatment underwent univariate analysis using log-rank tests and were then submitted to a multi-variate Cox-regression analysis (a = 5%). RESULTS One hundred fifteen children (12.3%) received or were planned to receive repeated dental treatment under general anaesthesia. In children receiving repeated dental treatment, the time intervals between first and second general anaesthesia and second and third general anaesthesia amounted to 22 ± 18 and 23 ± 20 months, respectively. The use of fluoridated toothpaste (HR: 0.28, p < 0.01) and attending 2 or more recall appointments per year (HR: 0.6, p < 0.01) significantly decreased the risk for repeated dental treatment under general anaesthesia in the multivariate model. CONCLUSION Adherence to preventive recall appointments and to oral hygiene recommendations is essential to maintain oral health and avoid repeated dental treatment under general anaesthesia.
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Affiliation(s)
- T König
- Department of Preventive Dentistry, Periodontology and Cariology, University Medical Center Göttingen, Germany
| | - P Reicherts
- Department of Preventive Dentistry, Periodontology and Cariology, University Medical Center Göttingen, Germany
| | - A Leha
- Department of Medical Statistics, University Medical Center Göttingen, Germany
| | - V Hrasky
- Department of Preventive Dentistry, Periodontology and Cariology, University Medical Center Göttingen, Germany
| | - A Wiegand
- Department of Preventive Dentistry, Periodontology and Cariology, University Medical Center Göttingen, Germany
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Haspert V, Wieser MJ, Pauli P, Reicherts P. Acceptance-Based Emotion Regulation Reduces Subjective and Physiological Pain Responses. Front Psychol 2020; 11:1514. [PMID: 32695054 PMCID: PMC7338768 DOI: 10.3389/fpsyg.2020.01514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 06/08/2020] [Indexed: 11/23/2022] Open
Abstract
Acceptance-based regulation of pain, which focuses on the allowing of pain and pain related thoughts and emotions, was found to modulate pain. However, results so far are inconsistent regarding different pain modalities and indices. Moreover, studies so far often lack a suitable control condition, focus on behavioral pain measures rather than physiological correlates, and often use between-subject designs, which potentially impede the evaluation of the effectiveness of the strategies. Therefore, we investigated whether acceptance-based strategies can reduce subjective and physiological markers of acute pain in comparison to a control condition in a within-subject design. To this end, participants (N = 30) completed 24 trials comprising 10 s of heat pain stimulation. Each trial started with a cue instructing participants to welcome and experience pain (acceptance trials) or to react to the pain as it is without employing any regulation strategies (control trials). In addition to pain intensity and unpleasantness ratings, heart rate (HR) and skin conductance (SC) were recorded. Results showed significantly decreased pain intensity and unpleasantness ratings for acceptance compared to control trials. Additionally, HR was significantly lower during acceptance compared to control trials, whereas SC revealed no significant differences. These results demonstrate the effectiveness of acceptance-based strategies in reducing subjective and physiological pain responses relative to a control condition, even after short training. Therefore, the systematic investigation of acceptance in different pain modalities in healthy and chronic pain patients is warranted.
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Affiliation(s)
- Valentina Haspert
- Department of Biological Psychology, Clinical Psychology, and Psychotherapy, Institute of Psychology, University of Würzburg, Würzburg, Germany
| | - Matthias J Wieser
- Department of Biological Psychology, Clinical Psychology, and Psychotherapy, Institute of Psychology, University of Würzburg, Würzburg, Germany.,Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Paul Pauli
- Department of Biological Psychology, Clinical Psychology, and Psychotherapy, Institute of Psychology, University of Würzburg, Würzburg, Germany.,Center of Mental Health (ZEP), University Hospital of Würzburg, Würzburg, Germany
| | - Philipp Reicherts
- Department of Biological Psychology, Clinical Psychology, and Psychotherapy, Institute of Psychology, University of Würzburg, Würzburg, Germany.,Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Augsburg, Germany
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Zerbini G, Ebigbo A, Reicherts P, Kunz M, Messman H. Psychosocial burden of healthcare professionals in times of COVID-19 - a survey conducted at the University Hospital Augsburg. Ger Med Sci 2020; 18:Doc05. [PMID: 32595421 PMCID: PMC7314868 DOI: 10.3205/000281] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/18/2020] [Indexed: 12/14/2022]
Abstract
Objective: The outbreak of COVID-19 was declared a pandemic by the WHO in March 2020. Studies from China, where the virus first spread, have reported increased psychological strain in healthcare professionals. The aim of this study was to investigate the psychosocial burden of physicians and nurses depending on their degree of contact with COVID-19 patients. In addition, we explored which supportive resources they used and which supportive needs they experienced during the crisis. Methods: Data were collected between March and April 2020 at the University Hospital Augsburg. A total of 75 nurses and 35 physicians, working either in a special COVID-19 ward or in a regular ward, took part in the survey. The participants filled in two standardized questionnaires (the Patient Health Questionnaire, PHQ; and the Maslach Burnout Inventory, MBI), and reported their fear of a COVID-19 infection and stress at work on a 10-point Likert scale. Finally, they answered three open-ended questions about causes of burden, supportive resources and needs during the crisis. Results: Nurses working in the COVID-19 wards reported higher levels of stress, exhaustion, and depressive mood, as well as lower levels of work-related fulfilment compared to their colleagues in the regular wards. Physicians reported similar scores independent of their contact with COVID-19 patients. The most common causes for burden were job strain and uncertainty about the future. Psychosocial support as well as leisure time were listed as important resources, and a better infrastructure adjustment to COVID-19 at the hospital (e.g. sufficient staff, keeping teams and working schedules stable) as suggestion for improvement. Conclusions: Our findings indicate that especially nurses working in COVID-19 wards are affected psychologically by the consequences of the pandemic. This might be due to a higher workload and longer time in direct contact with COVID-19 patients, compared to physicians.
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Affiliation(s)
- Giulia Zerbini
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Germany
| | - Alanna Ebigbo
- Medical Clinic III, University Hospital Augsburg, Germany
| | - Philipp Reicherts
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Germany
| | - Miriam Kunz
- Department of Medical Psychology and Sociology, Medical Faculty, University of Augsburg, Germany
| | - Helmut Messman
- Medical Clinic III, University Hospital Augsburg, Germany
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Reicherts P, Pauli P, Mösler C, Wieser MJ. Placebo Manipulations Reverse Pain Potentiation by Unpleasant Affective Stimuli. Front Psychiatry 2019; 10:663. [PMID: 31607964 PMCID: PMC6771171 DOI: 10.3389/fpsyt.2019.00663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 08/16/2019] [Indexed: 01/22/2023] Open
Abstract
According to the motivational priming hypothesis, unpleasant stimuli activate the motivational defense system, which in turn promotes congruent affective states such as negative emotions and pain. The question arises to what degree this bottom-up impact of emotions on pain is susceptible to a manipulation of top-down-driven expectations. To this end, we investigated whether verbal instructions implying pain potentiation vs. reduction (placebo or nocebo expectations)-later on confirmed by corresponding experiences (placebo or nocebo conditioning)-might alter behavioral and neurophysiological correlates of pain modulation by unpleasant pictures. We compared two groups, which underwent three experimental phases: first, participants were either instructed that watching unpleasant affective pictures would increase pain (nocebo group) or that watching unpleasant pictures would decrease pain (placebo group) relative to neutral pictures. During the following placebo/nocebo-conditioning phase, pictures were presented together with electrical pain stimuli of different intensities, reinforcing the instructions. In the subsequent test phase, all pictures were presented again combined with identical pain stimuli. Electroencephalogram was recorded in order to analyze neurophysiological responses of pain (somatosensory evoked potential) and picture processing [visually evoked late positive potential (LPP)], in addition to pain ratings. In the test phase, ratings of pain stimuli administered while watching unpleasant relative to neutral pictures were significantly higher in the nocebo group, thus confirming the motivational priming effect for pain perception. In the placebo group, this effect was reversed such that unpleasant compared with neutral pictures led to significantly lower pain ratings. Similarly, somatosensory evoked potentials were decreased during unpleasant compared with neutral pictures, in the placebo group only. LPPs of the placebo group failed to discriminate between unpleasant and neutral pictures, while the LPPs of the nocebo group showed a clear differentiation. We conclude that the placebo manipulation already affected the processing of the emotional stimuli and, in consequence, the processing of the pain stimuli. In summary, the study revealed that the modulation of pain by emotions, albeit a reliable and well-established finding, is further tuned by reinforced expectations-known to induce placebo/nocebo effects-which should be addressed in future research and considered in clinical applications.
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Affiliation(s)
| | - Paul Pauli
- Department of Psychology, University of Würzburg, Würzburg, Germany.,Center of Mental Health, University of Würzburg, Würzburg, Germany
| | - Camilla Mösler
- Department of Psychology, University of Würzburg, Würzburg, Germany
| | - Matthias J Wieser
- Department of Psychology, University of Würzburg, Würzburg, Germany.,Department of Psychology, Education, and Child Studies, University of Rotterdam, Rotterdam, Netherlands
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Juravle G, Reicherts P, Weinstein-Riechmann ML, Wieser M, von Leupoldt A. Psychophysiological correlates of affective picture processing during perceived and anticipated breathlessness. Biol Psychol 2017. [DOI: 10.1016/j.biopsycho.2017.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Reicherts P, Wiemer J, Gerdes AB, Schulz SM, Pauli P, Wieser MJ. Anxious anticipation and pain: the influence of instructed vs conditioned threat on pain. Soc Cogn Affect Neurosci 2017; 12:544-554. [PMID: 28008077 PMCID: PMC5390728 DOI: 10.1093/scan/nsw181] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 10/19/2016] [Accepted: 12/05/2016] [Indexed: 12/20/2022] Open
Abstract
Negative emotions such as anxiety enhance pain perception. However, certain threat characteristics are discussed to have different or even divergent effects on pain (hypoalgesia vs hyperalgesia). In order to investigate the neurobiological basis of different threats, we compared the impact of conditioned threat (CT) vs instructed threat (IT) on pain using fMRI. In two groups, participants underwent either Pavlovian threat conditioning or an instructed threat procedure. Afterwards, in an identical test phase participants watched the same visual cues from the previous phase indicating potential threat or safety, and received painful thermal stimulation. In the test phase, pain ratings were increased in both groups under threat. Group comparisons show elevated responses in amygdala and hippocampus for pain under threat in the CT group, and higher activation of the mid-cingulate gyrus (MCC) in the IT group. Psychophysiological interaction analyses in CT demonstrated elevated connectivity of the amygdala and the insula for the comparison of pain under threat vs safety. In IT, the same comparison revealed elevated functional connectivity of the MCC and the insula. The results suggest a similar pain augmenting effect of CT and IT, which, however, seems to rely on different networks mediating the impact of threat on pain.
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Affiliation(s)
| | - Julian Wiemer
- Department of Psychology, University of Würzburg, Würzburg, Germany
| | | | - Stefan M. Schulz
- Department of Psychology, University of Würzburg, Würzburg, Germany
| | - Paul Pauli
- Department of Psychology, University of Würzburg, Würzburg, Germany
| | - Matthias J. Wieser
- Department of Psychology, University of Würzburg, Würzburg, Germany
- Institute of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Wieser MJ, Reicherts P, Juravle G, von Leupoldt A. Attention mechanisms during predictable and unpredictable threat — A steady-state visual evoked potential approach. Neuroimage 2016; 139:167-175. [DOI: 10.1016/j.neuroimage.2016.06.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 05/18/2016] [Accepted: 06/14/2016] [Indexed: 01/12/2023] Open
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Wiemer J, Schulz SM, Reicherts P, Glotzbach-Schoon E, Andreatta M, Pauli P. Brain activity associated with illusory correlations in animal phobia. Soc Cogn Affect Neurosci 2014; 10:969-77. [PMID: 25411452 DOI: 10.1093/scan/nsu142] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 11/12/2014] [Indexed: 11/13/2022] Open
Abstract
Anxiety disorder patients were repeatedly found to overestimate the association between disorder-relevant stimuli and aversive outcomes despite random contingencies. Such an illusory correlation (IC) might play an important role in the return of fear after extinction learning; yet, little is known about how this cognitive bias emerges in the brain. In a functional magnetic resonance imaging study, 18 female patients with spider phobia and 18 healthy controls were exposed to pictures of spiders, mushrooms and puppies followed randomly by either a painful electrical shock or nothing. In advance, both patients and healthy controls expected more shocks after spider pictures. Importantly, only patients with spider phobia continued to overestimate this association after the experiment. The strength of this IC was predicted by increased outcome aversiveness ratings and primary sensory motor cortex activity in response to the shock after spider pictures. Moreover, increased activation of the left dorsolateral prefrontal cortex (dlPFC) to spider pictures predicted the IC. These results support the theory that phobia-relevant stimuli amplify unpleasantness and sensory motor representations of aversive stimuli, which in turn may promote their overestimation. Hyper-activity in dlPFC possibly reflects a pre-occupation of executive resources with phobia-relevant stimuli, thus complicating the accurate monitoring of objective contingencies and the unlearning of fear.
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Affiliation(s)
- Julian Wiemer
- Department of Psychology (Biological Psychology, Clinical Psychology, and Psychotherapy) and Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Stefan M Schulz
- Department of Psychology (Biological Psychology, Clinical Psychology, and Psychotherapy) and Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany Department of Psychology (Biological Psychology, Clinical Psychology, and Psychotherapy) and Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Philipp Reicherts
- Department of Psychology (Biological Psychology, Clinical Psychology, and Psychotherapy) and Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Evelyn Glotzbach-Schoon
- Department of Psychology (Biological Psychology, Clinical Psychology, and Psychotherapy) and Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Marta Andreatta
- Department of Psychology (Biological Psychology, Clinical Psychology, and Psychotherapy) and Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Paul Pauli
- Department of Psychology (Biological Psychology, Clinical Psychology, and Psychotherapy) and Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany Department of Psychology (Biological Psychology, Clinical Psychology, and Psychotherapy) and Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
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Abstract
The perception of unpleasant stimuli enhances whereas the perception of pleasant stimuli decreases pain perception. In contrast, the effects of pain on the processing of emotional stimuli are much less known. Especially given the recent interest in facial expressions of pain as a special category of emotional stimuli, a main topic in this research line is the mutual influence of pain and facial expression processing. Therefore, in this mini-review we selectively summarize research on the effects of emotional stimuli on pain, but more extensively turn to the opposite direction namely how pain influences concurrent processing of affective stimuli such as facial expressions. Based on the motivational priming theory one may hypothesize that the perception of pain enhances the processing of unpleasant stimuli and decreases the processing of pleasant stimuli. This review reveals that the literature is only partly consistent with this assumption: pain reduces the processing of pleasant pictures and happy facial expressions, but does not - or only partly - affect processing of unpleasant pictures. However, it was demonstrated that pain selectively enhances the processing of facial expressions if these are pain-related (i.e., facial expressions of pain). Extending a mere affective modulation theory, the latter results suggest pain-specific effects which may be explained by the perception-action model of empathy. Together, these results underscore the important mutual influence of pain and emotional face processing.
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Affiliation(s)
| | - Antje B M Gerdes
- Department of Psychology, University of Mannheim Mannheim, Germany
| | | | - Paul Pauli
- Department of Psychology, University of Würzburg Würzburg, Germany
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Rödig T, Reicherts P, Konietschke F, Dullin C, Hahn W, Hülsmann M. Efficacy of reciprocating and rotary NiTi instruments for retreatment of curved root canals assessed by micro-CT. Int Endod J 2014; 47:942-8. [DOI: 10.1111/iej.12239] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 01/01/2014] [Indexed: 11/27/2022]
Affiliation(s)
- T. Rödig
- Department of Preventive Dentistry Periodontology and Cariology; University Medical Center; Göttingen Germany
| | - P. Reicherts
- Department of Preventive Dentistry Periodontology and Cariology; University Medical Center; Göttingen Germany
| | - F. Konietschke
- Department of Medical Statistics; University Medical Center; Göttingen Germany
| | - C. Dullin
- Department of Diagnostic and Interventional Radiology; University Medical Center; Göttingen Germany
| | - W. Hahn
- Private Dental Practice; Göttingen Germany
| | - M. Hülsmann
- Department of Preventive Dentistry Periodontology and Cariology; University Medical Center; Göttingen Germany
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Kopf J, Dresler T, Reicherts P, Herrmann MJ, Reif A. The effect of emotional content on brain activation and the late positive potential in a word n-back task. PLoS One 2013; 8:e75598. [PMID: 24086584 PMCID: PMC3784459 DOI: 10.1371/journal.pone.0075598] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 08/17/2013] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION There is mounting evidence for the influence of emotional content on working memory performance. This is particularly important in light of the emotion processing that needs to take place when emotional content interferes with executive functions. In this study, we used emotional words of different valence but with similar arousal levels in an n-back task. METHODS We examined the effects on activation in the prefrontal cortex by means of functional near-infrared spectroscopy (fNIRS) and on the late positive potential (LPP). FNIRS and LPP data were examined in 30 healthy subjects. RESULTS BEHAVIORAL RESULTS SHOW AN INFLUENCE OF VALENCE ON THE ERROR RATE DEPENDING ON THE DIFFICULTY OF THE TASK: more errors were made when the valence was negative and the task difficult. Brain activation was dependent both on the difficulty of the task and on the valence: negative valence of a word diminished the increase in activation, whereas positive valence did not influence the increase in activation, while difficulty levels increased. The LPP also differentiated between the different valences, and in addition was influenced by the task difficulty, the more difficult the task, the less differentiation could be observed. CONCLUSIONS Summarized, this study shows the influence of valence on a verbal working memory task. When a word contained a negative valence, the emotional content seemed to take precedence in contrast to words containing a positive valence. Working memory and emotion processing sites seemed to overlap and compete for resources even when words are carriers of the emotional content.
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Affiliation(s)
- Juliane Kopf
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Würzburg, Würzburg Germany
| | - Thomas Dresler
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Würzburg, Würzburg Germany
- Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - Philipp Reicherts
- Department of Psychology, Biological Psychology, University of Würzburg, Würzburg, Germany
| | - Martin J. Herrmann
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Würzburg, Würzburg Germany
| | - Andreas Reif
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Würzburg, Würzburg Germany
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Reicherts P, Gerdes ABM, Pauli P, Wieser MJ. On the mutual effects of pain and emotion: facial pain expressions enhance pain perception and vice versa are perceived as more arousing when feeling pain. Pain 2013; 154:793-800. [PMID: 23541426 DOI: 10.1016/j.pain.2013.02.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 12/15/2012] [Accepted: 02/05/2013] [Indexed: 11/17/2022]
Abstract
Perception of emotional stimuli alters the perception of pain. Although facial expressions are powerful emotional cues - the expression of pain especially plays a crucial role for the experience and communication of pain - research on their influence on pain perception is scarce. In addition, the opposite effect of pain on the processing of emotion has been elucidated even less. To further scrutinize mutual influences of emotion and pain, 22 participants were administered painful and nonpainful thermal stimuli while watching dynamic facial expressions depicting joy, fear, pain, and a neutral expression. As a control condition of low visual complexity, a central fixation cross was presented. Participants rated the intensity of the thermal stimuli and evaluated valence and arousal of the facial expressions. In addition, facial electromyography was recorded as an index of emotion and pain perception. Results show that faces per se, compared to the low-level control condition, decreased pain, suggesting a general attention modulation of pain by complex (social) stimuli. The facial response to painful stimulation revealed a significant correlation with pain intensity ratings. Most important, painful thermal stimuli increased the arousal of simultaneously presented pain expressions, and in turn, pain expressions resulted in higher pain ratings compared to all other facial expressions. These findings demonstrate that the modulation of pain and emotion is bidirectional with pain faces being mostly prone to having mutual influences, and support the view of interconnections between pain and emotion. Furthermore, the special relevance of pain faces for the processing of pain was demonstrated.
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Affiliation(s)
- Philipp Reicherts
- Department of Psychology, Clinical Psychology, Biological Psychology, and Psychotherapy, University of Würzburg, Germany
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Wieser MJ, Gerdes ABM, Greiner R, Reicherts P, Pauli P. Tonic pain grabs attention, but leaves the processing of facial expressions intact-evidence from event-related brain potentials. Biol Psychol 2012; 90:242-8. [PMID: 22503790 DOI: 10.1016/j.biopsycho.2012.03.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Revised: 03/05/2012] [Accepted: 03/21/2012] [Indexed: 11/24/2022]
Abstract
Emotion and attention are key players in the modulation of pain perception. However, much less is known about the reverse influence of pain on attentional and especially emotional processes. To this end, we employed painful vs. non-painful pressure stimulation to examine effects on the processing of simultaneously presented facial expressions (fearful, neutral, happy). Continuous EEG was recorded and participants had to rate each facial expression with regard to valence and arousal. Painful stimulation attenuated visual processing in general, as reduced P100 and late positive potential (LPP) amplitudes revealed, but did not interfere with structural encoding of faces (N170). In addition, early perceptual discrimination and sustained preferential processing of emotional facial expressions as well as affective ratings were not influenced by pain. Thus, tonic pain demonstrates strong attention-demanding properties, but this does not interfere with concurrently ongoing emotion discrimination processes. These effects point at partially independent effects of pain on emotion and attention, respectively.
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Wieser MJ, Pauli P, Reicherts P, Mühlberger A. Don't look at me in anger! Enhanced processing of angry faces in anticipation of public speaking. Psychophysiology 2010; 47:271-80. [DOI: 10.1111/j.1469-8986.2009.00938.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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