Developing a treatment manual for attention management in chronic pain

This article reports the development of a protocol for the therapeutic application of "attention control" for chronic pain. Attention control is the limitation of the impact of pain by switching or retunning attention. An expert systems approach was used to develop the protocol. In the first stage an extensive literature search retrieved published and unpublished accounts of attention control strategies and a draft treatment manual was prepared. In the second stage 6 experts were recruited and they independently read and reviewed the draft manual. They were interviewed using a semi-structured protocol to elicit their views on the draft manual. The manual was then revised to accommodate the information and expertise. In addition to providing expert opinion on the manual the experts also raised issues about the process of change in psychological treatment for chronic pain. These issues were organized into a process model of change in chronic pain.     

Can exposure and acceptance strategies improve functioning and life satisfaction in people with chronic pain and whiplash-associated disorders (WAD)? A randomized controlled trial

Although 14% to 42% of people with whiplash injuries end up with chronic debilitating pain, there is still a paucity of empirically supported treatments for this group of patients. In chronic pain management, there is increasing consensus regarding the importance of a behavioural medicine approach to symptoms and disability. Cognitive behaviour therapy has proven to be beneficial in the treatment of chronic pain. An approach that promotes acceptance of, or willingness to experience, pain and other associated negative private events (e.g. fear, anxiety, and fatigue) instead of reducing or controlling symptoms has received increasing attention. Although the empirical support for treatments emphasizing exposure and acceptance (such as acceptance and commitment therapy) is growing, there is clearly a need for more outcome studies, especially randomized controlled trials. In this study, participants (N = 21) with chronic pain and whiplash-associated disorders were recruited from a patient organization and randomized to either a treatment or a wait-list control condition. Both groups continued to receive treatment as usual. In the experimental condition, a learning theory framework was applied to the analysis and treatment. The intervention consisted of a 10-session protocol emphasizing values-based exposure and acceptance strategies to improve functioning and life satisfaction by increasing the participants' abilities to behave in accordance with values in the presence of interfering pain and distress (psychological flexibility). After treatment, significant differences in favor of the treatment group were seen in pain disability, life satisfaction, fear of movements, depression, and psychological inflexibility. No change for any of the groups was seen in pain intensity. Improvements in the treatment group were maintained at 7-month follow-up. The authors discuss implications of these findings and offer suggestions for further research in this area.     

Can Exposure and Acceptance Strategies Improve Functioning and Life Satisfaction in People with Chronic Pain and Whiplash‐Associated Disorders (WAD)? A Randomized Controlled Trial

Although 14% to 42% of people with whiplash injuries end up with chronic debilitating pain, there is still a paucity of empirically supported treatments for this group of patients. In chronic pain management, there is increasing consensus regarding the importance of a behavioural medicine approach to symptoms and disability. Cognitive behaviour therapy has proven to be beneficial in the treatment of chronic pain. An approach that promotes acceptance of, or willingness to experience, pain and other associated negative private events (e.g. fear, anxiety, and fatigue) instead of reducing or controlling symptoms has received increasing attention. Although the empirical support for treatments emphasizing exposure and acceptance (such as acceptance and commitment therapy) is growing, there is clearly a need for more outcome studies, especially randomized controlled trials. In this study, participants (N = 21) with chronic pain and whiplash‐associated disorders were recruited from a patient organization and randomized to either a treatment or a wait‐list control condition. Both groups continued to receive treatment as usual. In the experimental condition, a learning theory framework was applied to the analysis and treatment. The intervention consisted of a 10‐session protocol emphasizing values‐based exposure and acceptance strategies to improve functioning and life satisfaction by increasing the participants' abilities to behave in accordance with values in the presence of interfering pain and distress (psychological flexibility). After treatment, significant differences in favor of the treatment group were seen in pain disability, life satisfaction, fear of movements, depression, and psychological inflexibility. No change for any of the groups was seen in pain intensity. Improvements in the treatment group were maintained at 7‐month follow‐up. The authors discuss implications of these findings and offer suggestions for further research in this area.     

Acceptance-based treatment for persons with complex, long standing chronic pain: a preliminary analysis of treatment outcome in comparison to a waiting phase

The concept of acceptance is receiving increased attention as an alternate approach to the suffering that is often associated with persistent and disabling pain. This approach differs from established treatments in that it does not principally focus on reducing pain, but on reducing the distressing and disabling influences of pain as they concern important areas in patients' lives. The present analyses represent a preliminary evaluation of an acceptance-based approach to chronic pain within an interdisciplinary treatment program. One hundred and eight patients with complex chronic pain conditions completed treatment and provided data for the current study. Treatment was conducted in a 3- or 4-week residential or hospital-based format. It included a number of exposure-based, experiential, and other behavior change methods focused on increasing (a) engagement in daily activity regardless of pain and (b) willingness to have pain present without responding to it. Significant improvements in emotional, social, and physical functioning, and healthcare use were demonstrated following treatment. The majority of improvements continued at 3-months post-treatment. Improvements in most outcomes during treatment were correlated with increases in acceptance, supporting the proposed process of treatment.     

Of witches,madmen, and products liability: An historical survey of the use of expert testimony

The United States Supreme Court's recent decision in Daubert v. Mewell Dour Pharmaceutical Inc. has focused attention on judicial treatment of expert testimony. A survey of the development of the forensic use of such testimony helps to explain the salient characteristics of modem American practice. The survey, in the context of medical experts, discloses a several centuries long trend toward an adversarial approach that places selection, preparation, and presentation of expert witness testimony ever more completely in the hands of the litigants. This trend has been challenged since at least the 1800s by those desiring an inquisitorial alternative featuring court's witnesses or neutral panels of experts. These proposals have generally been rejected. Daubert represents a modest step in the direction of greater judicial control of the presentation of expert evidence but raises questions about the evenhandedness of heightened judicial scrutiny of proffered expert testimony.     

Comparing the role of psychological flexibility and traditional pain management coping strategies in chronic pain treatment outcomes

Psychologically-based interventions for chronic pain traditionally include a mix of methods, including physical conditioning, training in relaxation or attention control, strategies to decrease irrational or dysfunctional thinking patterns, and activity management training. Recent developments suggest additional methods to promote acceptance, mindfulness, values-based action, and cognitive defusion (a cognitive process entailing change in the influences exerted by thoughts without necessarily changing their form or frequency). Collectively, these processes entail what is referred to as psychological flexibility. This study examined how changes in traditionally conceived methods of coping compare to changes in psychological flexibility in relation to improvements in functioning over the course of an interdisciplinary treatment program. Participants were 114 chronic pain sufferers. Results indicated that changes in the traditionally conceived methods were essentially unrelated to treatment improvements, while changes in psychological flexibility were consistently and significantly related to these improvements. We suggest that psychological flexibility appears highly relevant to the study of chronic pain and to future treatment developments. The utility of more traditionally conceived pain management strategies, on the other hand, may require a reappraisal.     

An expert–novice comparison of feature choice

Perceptual experts have learned to rapidly and accurately perceive the structural regularities that define categories and identities within a domain. They extract important features and their relations more efficiently than novices. We used fingerprint examination to investigate expert–novice differences in feature choice. On each fingerprint within our set, experts and novices selected one feature they thought was most useful for distinguishing a particular print and one feature they thought was least useful. We found that experts and novices often differed in the features they chose, and experts tended to agree more with each other. However, any such expert–novice difference appeared to depend on the image at hand typically emerging when salient or more conspicuous features of a fingerprint were unclear. We suggest that perceptual training ought to direct attention to useful features with the understanding that what is useful may change depending on the clarity of the stimuli.     

Predicting the present: expert testimony and civil commitment

This article uses the Supreme Court's decision in Daubert as an opportunity to address a chronic concern regarding the disparity between mental health law as officially enunciated and the practical application of that law. After Daubert, admissibility of expert evidence under the federal rules requires a qualified expert, a reliable basis for the testimony, and relevance to the legal issue. Ongoing psychological research pursues empirical data that expands the scope of psychological expertise and clarifies its limits. This article addresses the requirement of relevance by examining the logical relationship between the psychologist's actuarial and clinical expertise and the legal issues addressed by the court in civil commitment proceedings. Ideally, Daubert might stimulate a process of cooperative analysis in which psychologists and lawyers clarify the proper roles of psychological experts and of the courts with which those experts interact. This article begins that project by clarifying the legal determination required in civil commitment proceedings and by explicating the relationship between the responsibilities of experts and those of courts.     

The effects of age and musculoskeletal pain on force variability among manual workers

The present study investigated the influence of age and musculoskeletal pain on force variability during a continuous isometric handgrip force task performed at 30% of maximal voluntary contraction carried out until failure. We recruited 96 male manual workers aged 51–72 years. The participants were stratified according to their age (50–59 and 60+ years) and by pain status (no pain, acute pain and chronic pain). The amplitude and structure of variability expressed as respectively standard deviation (SD) and coefficient of variation (CV), and sample entropy (SaEn) were calculated from the endurance task. The oldest group had an approximately 18% longer endurance time than the youngest group. No between-group differences were found in SD or CV, whereas a significant interaction between age and pain stage was found for SaEn. The youngest group showed lower SaEn than the oldest for both those with chronic pain and those without pain, indicating less force complexity, whereas a tendency for the opposite was found in the acute pain group. Within the pain stage groups, workers with acute pain had higher SaEn compared with both the no pain and chronic pain groups. These findings suggest that age and musculoskeletal pain differentially affects the structure of force variability in manual workers.     

Cognitive Behavioral Therapy for Postamputation Chronic Pain: A Case Report

Limb amputation has a significant impact on an individual, not only physically but emotionally. Consequences of both traumatic and atraumatic amputations are vast and can result in functional disability, impaired emotional functioning, and changes in overall quality of life. These consequences may be further complicated by the development of chronic pain. Traditional management of postamputation chronic pain often involves invasive procedures and pharmacotherapy. While research notes behavioral interventions, such as cognitive-behavioral therapy (CBT) as a viable treatment alternative for chronic pain, there is no literature supporting CBT for postamputation chronic pain. In this case report, we present a 63-year-old male lower limb amputee complicated with chronic pain who experienced pain reduction and improved quality of life following manualized treatment with CBT for chronic pain. Treatment took place over 12 sessions with fidelity (93%) being measured throughout to ensure accurate utilization of the treatment manual. As part of the treatment manual, self-report measures (Pain Rating Scale, Pain Catastrophizing Scale, Pain Outcomes Questionnaire, and subjective units of distress) were used throughout to track patient progress. All measures showed improvement with the biggest gains being seen in pain ratings and pain catastrophizing.     

Expertise in basketball modifies perceptual discrimination abilities,underlying cognitive processes,and visual behaviours

In this paper, the links between cognitive constraints, visual behaviours, and perceptual judgements are examined. Two experiments investigated the perceptual processes employed during same-different judgement tasks. In Experiment 1, experts' eye movements (i.e., number of fixations and fixation duration) were consistent across discrepant source and target conditions where the number of displaced elements was manipulated. In contrast, novices decreased the number of fixations employed as the number of elements displaced increased. The findings are consistent with the view that both experts and novices process information in a manner (relational or attributional) that constrains the type of visual search used (low or high sensitive to attributional change). In Experiment 2, manipulation of target presentation confirmed that recognition was viewpoint dependent for both expert and novice players. The degradation in performance was accompanied by a change in the visual search behaviours employed by experts, which confirmed thr strength of the search–cognition–performance links     

Eyewitness memory is still not common sense: comparing jurors,judges and law enforcement to eyewitness experts

Knowledge of factors affecting eyewitness accuracy was examined in a sample of jurors, judges and law enforcement professionals. Participants completed a survey in which they were asked to agree or disagree with 30 statements about eyewitness issues, and their responses were compared to a sample of eyewitness experts who completed the same survey. Participant responses differed significantly from responses of eyewitness experts. Jurors disagreed with the experts on 87% of the issues, while judges and law enforcement disagreed with the experts on 60% of the issues. The findings show a large deficiency in knowledge of eyewitness memory amongst jurors, judges and law enforcement personnel, indicating that the legal system may benefit from expert assistance in the evaluation of eyewitness evidence. Copyright © 2005 John Wiley & Sons, Ltd.     

Multiple risk expert systems interventions: impact of simultaneous stage-matched expert system interventions for smoking, high-fat diet, and sun exposure in a population of parents.

Three stage-based expert system interventions for smoking, high-fat diet, and unsafe sun exposure were evaluated in a sample of 2,460 parents of teenagers. Eighty-four percent of the eligible parents were enrolled in a 2-arm randomized control trial, with the treatment group receiving individualized feedback reports for each of their relevant behaviors at 0, 6, and 12 months as well as a multiple behavior manual. At 24 months, the expert system outperformed the comparison condition across all 3 risk behaviors, resulting in 22% of the participants in action or maintenance for smoking (vs. 16% for the comparison condition), 34% for diet (vs. 26%), and 30% for sun exposure (vs. 22%). Proactive, home-based, and stage-matched expert systems can produce significant multiple behavior changes in at-risk populations where the majority of participants are not prepared to change.     

Haste does not always make waste: Expertise,direction of attention,and speed versus accuracy in performing sensorimotor skills

In two experiments, we examined the attentional mechanisms governing sensorimotor skill execution across levels of expertise. In Experiment 1, novice and expert golfers took a series of putts under dual-task conditions designed to distract attention from putting and under skill-focused conditions that prompted attention to step-by-stePperformance. Novices performed better under skill-focused than under dual-task conditions. Experts showed the opposite pattern. In Experiment 2, novice and expert golfers putted under instructions that emphasized either putting accuracy or speed—the latter intended to reduce the time available to monitor and explicitly adjust execution parameters. Novices putted better under accuracy instructions. Experts were more accurate under speed instructions. In agreement with theories of skill acquisition and automaticity, novice performance is enhanced by conditions that allow for on-line attentional monitoring (e.g., skill-focused or accuracy instructions) in comparison with conditions that prevent explicit attentional control of skill execution (e.g., dual-task or speed constraints). In contrast, the proceduralized skill of experts benefits from environments that limit, rather than encourage, attention to execution.     

Short report: The effect of expertise in hiking on recognition memory for mountain scenes

The nature of an expert memory advantage that does not depend on stimulus structure or chunking was examined, using more ecologically valid stimuli in the context of a more natural activity than previously studied domains. Do expert hikers and novice hikers see and remember mountain scenes differently? In the present experiment, 18 novice hikers and 17 expert hikers were presented with 60 photographs of scenes from hiking trails. These scenes differed in the degree of functional aspects that implied some action possibilities or dangers. The recognition test revealed that the memory performance of experts was significantly superior to that of novices for scenes with highly functional aspects. The memory performance for the scenes with few functional aspects did not differ between novices and experts. These results suggest that experts pay more attention to, and thus remember better, scenes with functional meanings than do novices.     

Short report: the effect of expertise in hiking on recognition memory for mountain scenes

The nature of an expert memory advantage that does not depend on stimulus structure or chunking was examined, using more ecologically valid stimuli in the context of a more natural activity than previously studied domains. Do expert hikers and novice hikers see and remember mountain scenes differently? In the present experiment, 18 novice hikers and 17 expert hikers were presented with 60 photographs of scenes from hiking trails. These scenes differed in the degree of functional aspects that implied some action possibilities or dangers. The recognition test revealed that the memory performance of experts was significantly superior to that of novices for scenes with highly functional aspects. The memory performance for the scenes with few functional aspects did not differ between novices and experts. These results suggest that experts pay more attention to, and thus remember better, scenes with functional meanings than do novices.     

Automatic processing of pain: the change of implicit pain associations after psychotherapy

This study explores the utility of a pain IAT for the assessment of dysfunctional cognitive beliefs in chronic pain patients before and after a cognitive behaviour therapy. A patient group suffering from chronic pain (N=25) treated with a 4-week cognitive behavioural psychotherapy is compared with an untreated healthy control group (N=27) at two points in time. In addition, both groups completed a self-esteem questionnaire (Rosenberg-scale) and a self-esteem IAT. In the clinical group a questionnaire assessing self-reported pain cognitions was administered. The pain IAT was able to differentiate between chronic pain patients and healthy controls before the treatment. Most important, pain-related implicit associations could be shown to change over the course of treatment in the clinical group of chronic pain patients. Results provide first evidence for an application of the IAT in chronic pain research.     

Strategy Shifts and Expertise in Solving Transformation Rule Problems

The acquisition of expertise in formal problem solving has been assumed to involve either a shift from backwards to forwards inference, or a shift from unguided to guided forwards inference. In a longitudinal study, the acquisition of formal problem-solving expertise was investigated. Participants were tested as novices before undertaking controlled practice in the problem domain which involved transformation rule problems, and were finally tested as experts. The direction of inference in problem solutions was found to be inadequate to describe the strategic differences between novices and experts. Therefore, a new solution coding system was applied, based on atomic components of problem solution. Analysis of novice and expert solutions revealed no systematic strategy in the novice stage—solutions were confused and contained unproductive steps and backtracking. Several strategies were found in the expert solutions, but they did not agree with previously reported results. It was therefore proposed that the acquisition of expertise does not involve a change from one specific solution strategy to another, but rather the development of an efficient strategy, which can differ between participants.     

Attention modification in persons with fibromyalgia: a double blind, randomized clinical trial

Contemporary models of chronic musculoskeletal pain emphasize the critical roles of fear, anxiety, and avoidance as well as biases in attention in the development and maintenance of chronic pain disability. Evidence supports the influence of individual difference variables such as anxiety sensitivity, pain-related anxiety, and catastrophizing on the pain experience and on pain-related attentional biases. Changes in attentional biases have been associated with treatment gains in patients with clinically significant anxiety. The Attentional Modification Paradigm (AMP) is a modification of the dot-probe paradigm used to facilitate such changes in attentional biases. Given the relationship between chronic musculoskeletal pain and anxiety, AMP may be effective in reducing pain as well. Participants included persons (n = 17) with fibromyalgia and were randomly assigned to either an AMP condition or a control condition. The participants completed two 15-minute AMP sessions per week for 4 weeks. Those in the AMP condition reported statistically significant and substantial reductions on several individual difference variables relative to those in the control condition, and a greater proportion experienced clinically significant reductions in pain. These preliminary results offer a promising new avenue for treating chronic musculoskeletal pain that warrants additional research. Comprehensive results, limitations, and future directions are discussed.     

Expertise, Democracy, and Applied Ethics

Is expertise in applied ethics compatible with individual autonomy and democratic self-governance? This depends on whether a ‘tracking condition’ is satisfied for expert claims about issues in applied ethics. This condition requires that, when expert deliberations are properly conducted they ‘track’ the courses of reasoning that the experts’ clients would themselves have undertaken if they had (perhaps subject to certain conditions) considered the matters for themselves. Pluralism of the kind thematised by Isaiah Berlin and Stuart Hampshire suggests that the tracking condition typically will not be satisfied and, hence, that whatever experts are praticising in applied ethics they are doing it contrary to democratic principles of autonomy and self-government. The implications of this result are sketched and some standard objections briefly considered.