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.     

Strategic and automatic threat processing in chronic musculoskeletal pain: a startle probe investigation

Attentional bias research with chronic pain samples has yielded conflicting results. In the present investigation the startle paradigm was used to test the postulate that fear-based mechanisms play an important role in attentional biases for pain-related threat in chronic pain. Participants, including 31 individuals with chronic musculoskeletal pain and 20 healthy controls, completed a startle task designed to measure attention to different types of words (neutral vs sensory pain vs affective pain vs health catastrophe) presented at different levels of cognitive processing (strategic vs automatic). Measures of fear-based individual difference variables, including anxiety sensitivity and fear of pain, were also completed. Startle amplitudes and latencies to acoustic startle probes that followed word presentations were recorded. Data were analyzed with repeated measures ANOVAs and correlational analysis. Significant between-group differences were found indicating that, relative to chronic pain participants, healthy controls had higher startle amplitude index scores for health catastrophe words. There was also a trend among patients with chronic pain for greater startle amplitude index scores for strategic presentations of sensory pain words. In the automatic condition, all participants demonstrated a lower startle latency index for sensory words relative to both affect and health catastrophe words, suggesting participants had more difficulty disengaging from affect and health catastrophe words or were more avoidant of sensory words. Correlational analyses indicated that startle response indices for words related to health catastrophe became more pronounced for chronic pain patients as anxiety sensitivity and fear of pain increased. Implications and directions for future research are discussed.     

The role of athletes' pain-related anxiety in pain-related attentional processes

Numerous researchers have highlighted the social determinants of athletes' attitude toward pain, yet little is known about the role of cognitive processes and emotions that are related to pain in sport endeavors. There is evidence, in a dot probe paradigm, that individuals with chronic pain selectively orient their attention toward pain-related stimuli, but no studies have differentiated between the two attentional processes of hypervigilance that are evident in athletes: facilitated detection of threat and difficulty in disengaging attention from threatening stimuli. In the present study using a dot probe paradigm, we examined whether professional rugby players (N=58) with high pain-related anxiety (HPA) would show an attentional bias for pain-related threat, and whether this hypervigilance would reflect difficulty disengaging from threat or facilitated detection of threat. Rugby players with HPA oriented their attention toward pain-related threat with a concomitant difficulty disengaging from threat. Difficulty disengaging from painful stimuli may increase anxiety, and thus be maladaptive in sport. This is the first study to identify pain-related anxiety as a vulnerability marker in athletes' attentional biases.     

Strategic and Automatic Threat Processing in Chronic Musculoskeletal Pain: A Startle Probe Investigation

Attentional bias research with chronic pain samples has yielded conflicting results. In the present investigation the startle paradigm was used to test the postulate that fear‐based mechanisms play an important role in attentional biases for pain‐related threat in chronic pain. Participants, including 31 individuals with chronic musculoskeletal pain and 20 healthy controls, completed a startle task designed to measure attention to different types of words (neutral vs sensory pain vs affective pain vs health catastrophe) presented at different levels of cognitive processing (strategic vs automatic). Measures of fear‐based individual difference variables, including anxiety sensitivity and fear of pain, were also completed. Startle amplitudes and latencies to acoustic startle probes that followed word presentations were recorded. Data were analyzed with repeated measures ANOVAs and correlational analysis. Significant between‐group differences were found indicating that, relative to chronic pain participants, healthy controls had higher startle amplitude index scores for health catastrophe words. There was also a trend among patients with chronic pain for greater startle amplitude index scores for strategic presentations of sensory pain words. In the automatic condition, all participants demonstrated a lower startle latency index for sensory words relative to both affect and health catastrophe words, suggesting participants had more difficulty disengaging from affect and health catastrophe words or were more avoidant of sensory words. Correlational analyses indicated that startle response indices for words related to health catastrophe became more pronounced for chronic pain patients as anxiety sensitivity and fear of pain increased. Implications and directions for future research are discussed.     

Attentional Bias Modification in People with Chronic Pain: A Proof of Concept Study

The purpose of this proof of concept study was to explore the role of attentional bias modification (ABM) in improving clinically relevant outcomes in chronic pain. Eight participants with chronic pain completed eight ABM sessions, which featured a modified version of the visual-probe task implicitly training attention away from pain-related stimuli towards neutral stimuli. Training sessions included a variety of linguistic and pictorial pain-related stimuli, which were presented at two presentation times (500 and 1250 ms). Participants also completed a standard version of the visual-probe task pre- and post-ABM to assess changes in bias. The primary outcome measure was pain intensity, and secondary outcome measures were anxiety, depression severity and pain interference. Statistically and clinically significant change was shown pre- to post-ABM in pain intensity, anxiety, depression and pain interference. Attentional bias scores did not statistically differ across time. These results support the continued exploration of ABM in chronic pain and the modifications we made to the intervention (i.e. the inclusion of pictorial stimuli and a longer presentation time). Future research is needed to explore the optimal form of ABM and whether improvements are maintained over time.     

Prediction of experimental pain sensitivity by attention to pain-related stimuli in healthy individuals

The aim of the present study was to assess the predictive power of the processing of pain-related information, comprising concepts of hypervigilance to pain, pain catastrophizing, and pain-related anxiety (questionnaires) as well as attentional processes related to pain-related stimuli (dot-probe task) in explaining individual differences in experimental pain sensitivity (pressure/thermal pain threshold). In 160 healthy participants (ages 13-61; 80 females), results of hierarchical multiple regression analyses showed that self-reported hypervigilance contributed significantly to the prediction of pain sensitivity, whereas pain catastrophizing and anxiety did not. However, inconsistent with prediction, the effect was in the opposite direction, indicating that vigilance to pain sensations or stimuli is associated with lower pain sensitivity in healthy individuals. Entering the attentional bias indices from the dot-probe task showed that an increased bias to pain words is related to higher experimental pain sensitivity, which confirms the hypothesis.     

Illness perceptions are the main predictors of depression and anxiety symptoms in patients with chronic pain

Depression and anxiety symptoms in chronic pain are associated with adverse clinical outcomes, and appear highly related to patient’s illness perceptions as well as with marital adjustment. This study aimed to investigate the predictive value of pain variables, marital adjustment and illness perceptions on depression and anxiety in patients with chronic pain. Two hundred patients were recruited from a pain unit in a public hospital in the north of Portugal. Patients completed a questionnaire that assessed illness perceptions (IPQ-Brief), marital adjustment (revised dyadic adjustment scale), depression and anxiety symptoms (hospital anxiety depression scale) and pain variables (pain intensity and pain disability index). Depression and anxiety symptoms were associated with pain intensity, pain-related disability, marital adjustment and illness perceptions. Results from hierarchical regression showed that illness perceptions contributed significantly to depression and anxiety symptoms over and above the effects of pain intensity, pain-related disability and marital adjustment, after controlling for gender. In multivariate analyses, pain intensity, pain-related disability and marital adjustment were uniquely related to depression and anxiety symptoms, whereas specific illness perceptions were uniquely related to depression symptoms (identity, treatment control, emotional response and coherence) and to anxiety symptoms (identity, emotional response and concern). Perceptions of greater symptomatology (identity) and of emotional impact, and lesser perceptions of treatment control and understanding of chronic pain (illness comprehensibility) were significantly associated with increased depression symptoms. Perceptions of greater symptomatology (identity), emotional impact and greater concern were associated with anxiety symptoms. These findings indicate that the contribution of illness perceptions was greater than that made by traditional covariates, and may therefore be a useful basis for future psychological interventions.     

Social phobia in disabled workers with chronic musculoskeletal pain

The present study assessed the prevalence and impact of social phobia and other anxiety disorders in disabled workers with chronic musculoskeletal pain. Potential participants were 200 disabled workers consecutively referred to an interdisciplinary tertiary care centre. A two stage screening process was used in which: (a) a self-report battery was given during a pre-admission visit, and (b) preplanned selection criteria were applied to the self-report instruments to select patients for a structured diagnostic interview. Fifty-four of the 146 patients who provided complete responses on the self-report battery met criteria for interview. Twenty-six patients (17.8%) met DSM-IV criteria for a current anxiety disorder and, of these, 16 (11.0%) were diagnosed with social phobia. Subjects with social phobia rated themselves as having less social support than subjects with no psychiatric disorder, but the groups did not differ in pain-related life interference, personal control, or health care utilization. The results suggest that social phobia is over-represented in disabled workers with chronic musculoskeletal pain and should be noted as a comorbid condition that may compound both suffering and disability.     

Cognitive factors influence outcome following multidisciplinary chronic pain treatment: a replication and extension of a cross-lagged panel analysis

Reducing maladaptive cognitions is hypothesized to constitute an active therapeutic process in multidisciplinary pain programs featuring cognitive-behavioral interventions. A cross-lagged panel design was used to determine whether: a) early-treatment cognitive changes predicted late-treatment pain, interference, activity and mood changes, but not vice versa; b) three cognitive factors made unique contributions to outcome; c) substantial cognitive changes preceded substantial improvements in outcome. Sixty-five chronic pain patients, participating in a 4-week multidisciplinary program, completed measures of pain helplessness, catastrophizing, pain-related anxiety (process factors), pain severity, interference, activity level and depression (outcomes) at pre-, mid- and posttreatment. Results showed that early-treatment reductions in pain helplessness predicted late-treatment decreases in pain and interference, but not vice versa, and that early-treatment reductions in catastrophizing and pain-related anxiety predicted late-treatment improvements in pain severity, but not vice versa. Findings suggested that the three process factors predicted improvements mostly in common. However, little evidence was found that large early-treatment reductions in process variables preceded extensive improvements in pain. Findings replicate those of a recent report regarding cross-lagged effects, and offer support that cognitive changes may indeed influence late-treatment changes in outcomes.     

疼痛恐惧的神经机制及其消退

疼痛恐惧是疼痛基础和临床研究中的一个重要课题。个体对疼痛信息产生过度警觉,诱发不恰当的回避行为,扰乱机体的正常功能,加剧疼痛的现象即为疼痛恐惧。疼痛恐惧可影响个体的疼痛感知以及疼痛相关的注意和回避行为,且在慢性疼痛(如慢性肌骨骼疼痛)的发展、维持个体正常生理功能的丧失中起着重要作用。疼痛恐惧的形成与表达涉及杏仁核、海马、背侧前扣带回皮层、和前额叶皮层等脑区的参与。当前的疼痛恐惧消退的心理-行为干预方法可在疼痛恐惧加工的不同阶段(巩固、再巩固和消退)消退个体的疼痛恐惧。然而,由于恐惧记忆形成过程较为复杂并受多种因素影响,疼痛恐惧记忆消退方法效果较不稳定,其基础研究与临床应用之间仍存在较大的鸿沟。将来研究有必要考虑到疼痛恐惧形成环境的差异以及个体人格特质/心理状态的差异,逐步完善相关消退方法并将其引入临床镇痛,以期帮助患者弱化、擦除甚至改写困扰他们的疼痛恐惧,从而缓解甚至消除病患的疼痛。     

Combining computerized home-based treatments for generalized anxiety disorder: an attention modification program and cognitive behavioral therapy

Generalized anxiety disorder (GAD) is a common and disabling condition associated with significant personal and societal costs. Although efficacious treatments exist for GAD, the majority of these individuals fail to access our most effective treatments. In the current paper, we report the results of an open trial that examined the efficacy of a computer-delivered home-based treatment program for GAD. Twenty-one individuals seeking treatment for GAD received a self-administered program over 6 weeks that comprised two components: (1) an Attention Modification Program (AMP) designed to facilitate attentional disengagement from threat-relevant stimuli and (2) brief computer-delivered cognitive and behavioral treatment modules (CCBT). Fourteen of the 21 enrolled participants (67%) completed the treatment program. Intent-to-treat and completer analyses revealed that AMP+CCBT resulted in significant reductions in clinician- and self-rated symptoms of anxiety, worry, depression, and functional impairment. Moreover, treatment completers displayed significant reductions in attentional bias for threat from pre- to postassessment. Change in attentional bias for threat from pre- to postassessment was associated with change in worry symptoms. Finally, 79% of participants no longer met DSM-IV criteria for GAD at postassessment and 36% were classified as remitted (Hamilton Rating Scale for Anxiety ≤7; Rickels et al., 2006). These results suggest that computer-delivered AMP+CCBT may serve as an effective and easily accessible treatment option for individuals with GAD.     

Multimethod assessment of treatment process in chronic low back pain: comparison of reported pain-related anxiety with directly measured physical capacity

Although cognitive behavioural treatments (CBT) have proven efficacy in improving symptom management, pain-related distress, physical performance and return to work. few studies have examined the relationship between changes in behavioural process variables during treatment and improvement in outcome variables following treatment. We designed a multimethod assessment strategy to test the relative contribution of changes in physical capacity and pain-related anxiety to treatment outcome variables. Low back pain patients (n = 59) were treated with an intensive programme of physical exercise and CBT. Comparisons from pre- to post-treatment showed significant improvement in pain severity, interference, affective distress, activity level, and depression. Improvements in pain-related anxiety were associated with improvements in all outcome variables except interference. Of three physical capacity composite scores, improvement in only one (lumbar extension and flexion capacity) was associated with improvements in all outcome variables except interference. Further analyses demonstrated that the relationship between changes in pain-related anxiety and treatment outcome were independent of changes in physical capacity performance. Changes during treatment in pain-related anxiety may be more important than changes during treatment in physical capacity when predicting the effect of treatment on behavioural outcome measures. These results are discussed in the context of how to improve assessment of the chronic pain patient and improve the effectiveness of multidisciplinary CBT.     

Anxiety at 13 and its effect on pain,pain-related anxiety,and pain-related disability at 17: An ALSPAC cohort longitudinal analysis

The aim of the present study was to investigate the influence of anxiety at 13 years of age on the presence of chronic pain, pain-related anxiety, and pain-related disability at 17 years of age in a large longitudinal cohort. We hypothesized that mother-reported anxiety at 13 would be associated with the presence of chronic pain at 17 and an increase in pain-related anxiety using all available data from the longitudinal cohort. Further, we hypothesized that anxiety at 13 would predict pain-related disability in adolescents who reported chronic pain at 17 years of age. Participants were recruited from the Avon Longitudinal Study of Parents and Children based in the UK who attended a university research clinic at 17. Child anxiety (reported by the mother) was extracted at child age 13, and self-report of the presence of chronic pain, pain-related anxiety, and pain-related disability at 17. Analyses revealed that child anxiety at 13 was not significantly associated with the presence of chronic pain at 17 (n = 842). However, anxiety at 13 was significantly associated with pain-related anxiety at 17 (n = 1831). For the subsample of adolescents who reported chronic pain, anxiety at 13 was associated with pain-related disability at 17 (n = 393). Further analyses revealed that pain-related anxiety at 17 mediated the association between anxiety at 13 and pain-related disability at 17, suggesting that pain-related anxiety should be a target for treatment in adolescents with chronic pain, to reduce the impact of pain in later adolescence. General anxiety at 13 was unrelated to the presence of chronic pain at 17, but should be considered a risk factor for later pain-related anxiety and disability in a subset of adolescents who develop chronic pain.     

The self regulatory effect of attentional control in modulating the relationship between attentional biases toward threat and anxiety symptoms in children

The present study examined the associations between attentional biases to threat, attentional control and anxiety in a sample of children aged 9 to 14. It was hypothesised that the association between attentional biases toward threat and anxiety might be stronger when the ability to control attention is reduced. The study employed pictures of neutral, happy and angry facial expressions as they have greater ecological value compared to words. Children completed a dot-probe task measuring attentional biases toward such stimuli. They also completed the Spence child anxiety scale for anxiety symptoms and, for attentional control, the child version of the attention control scale measuring the ability to focus and shift attention. Results of a hierarchical regression analysis showed that attentional control significantly explained anxiety. Furthermore, the interaction between attentional control and attentional biases significantly explained anxiety level. These results indicate that attentional control moderates the relation between attentional biases toward threatening facial expressions and anxiety in children. Additionally, a discussion about a possible protective role of attentional control is provided.     

Treatment of Insomnia within an Interdisciplinary Pain Rehabilitation Program: A Randomized Trial

Background/ObjectivePrior research indicates interdisciplinary pain rehabilitation program (IPRP) usual care (UC) does not sufficiently address sleep problems among individuals with comorbid chronic pain and clinical levels of insomnia. Cognitive behavioral therapy for insomnia (CBT-I) is an evidence-based insomnia intervention. The current study investigates the translation of CBT-I into an IPRP.MethodIn this single-site, prospective, randomized controlled pilot study, insomnia and pain-related outcomes were examined for adults participating in a 10-week IPRP (N = 79) who were allocated to a 4-session group-based CBT-I (IPRP+CBT-I) or usual care (IPRP-UC) condition.ResultsPatients in the IPRP+CBT-I group showed improvements in insomnia symptoms at the end compared to the beginning of the CBT-I group; however, there were no IPRP outcome differences relative to the IPRP-UC condition. Both groups reported statistically significant reductions in insomnia, pain severity, pain-related life interference, and depressed mood. Fewer than one-third of participants reported clinically meaningful reductions in insomnia symptoms following IPRP participation.ConclusionsFurther efforts are needed to address sleep problems in pain rehabilitation settings.     

Pain anxiety, acceptance, and outcomes among individuals with HIV and chronic pain: a preliminary investigation

The current study investigated the role of during treatment changes in pain anxiety in the relation between during treatment changes in pain acceptance and chronic pain outcomes. Participants included 45 (15 women) adults (M_age = 50.42, SD = 7.69) who were HIV positive and experienced chronic pain. They were offered 12 weekly, 90-min group CBT sessions to increase understanding about chronic pain and to improve coping skills. Four hierarchical regression analyses were conducted to examine the mediating role of treatment changes in pain anxiety in the relation between treatment changes in pain acceptance and chronic pain outcomes. Results suggest that increases in pain acceptance during treatment were associated with decreased levels of pain anxiety during treatment, as well as decreases in pain-related impairment at treatment completion. Furthermore, decreases in pain anxiety during treatment were associated with decreases in pain-related impairment at treatment completion. Finally, treatment changes in pain anxiety were found to partially mediate the association between treatment changes in pain acceptance and pain-related impairment at treatment completion. Results are discussed within the context of better understanding the processes of change within a CBT model for chronic pain patients.     

The Influence of Anticipatory Processing on Attentional Biases in Social Anxiety

Research on cognitive theories of social anxiety disorder (SAD) has identified individual processes that influence this condition (e.g., cognitive biases, repetitive negative thinking), but few studies have attempted to examine the interaction between these processes. For example, attentional biases and anticipatory processing are theoretically related and have been found to influence symptoms of SAD, but they rarely have been studied together (i.e., Clark & Wells, 1995). Therefore, the goal of the current study was to examine the effect of anticipatory processing on attentional bias for internal (i.e., heart rate feedback) and external (i.e., emotional faces) threat information. A sample of 59 participants high (HSA) and low (LSA) in social anxiety symptoms engaged in a modified dot-probe task prior to (Time 1) and after (Time 2) an anticipatory processing or distraction task. HSAs who anticipated experienced an increase in attentional bias for internal information from Time 1 to Time 2, whereas HSAs in the distraction condition and LSAs in either condition experienced no changes. No changes in biases were found for HSAs for external biases, but LSAs who engaged in the distraction task became less avoidant of emotional faces from Time 1 to Time 2. This suggests that anticipatory processing results in an activation of attentional biases for physiological information as suggested by Clark and Wells.     

Cognitive-behaviour therapy in the treatment of chronic, occupational pain of the upper limbs: a 2 yr follow-up.

Nineteen Ss who experienced chronic, occupational pain of the upper limbs and who had previously completed a programme of either individual or group cognitive-behaviour therapy were followed up 2 yr later. Significant improvements on measures of depression, anxiety, coping strategies and interference in daily living were found following treatment. Such improvements were not evident for the waiting list control Ss and no difference was found between group vs individual applications of therapy. A 2 yr follow-up, significant improvements from pre-treatment levels were evident for depression, coping strategies, significant other report of disability, self monitored pain and distress caused by pain. While there was generally little evidence of relapse, a significant decline from post-treatment levels was found for the individual therapy condition compared to the group therapy condition on measures of self monitored pain and interference caused by pain. Since post-treatment levels tended to be somewhat superior for the individual therapy condition, the overall finding at 2 yr follow-up was of minimal difference in outcome for group vs individual forms of cognitive-behaviour therapy. Despite improvements from pre-treatment levels, the vast majority of Ss still reported significant and distressing levels of pain at 2 yr follow-up.     

Altered processing of health threat words as a function of hypochondriacal tendencies and experimentally manipulated control beliefs

Attentional biases associated with various forms of psychopathology have been well documented. Few studies, however, have assessed the factors that moderate these biases. The present paper assesses the biased processing of health words as a function of hypochondriacal tendencies during a threat of bioterrorism (anthrax), and whether perceived control can moderate those biases. Based on a sample of 328 participants, hypochondriacal tendencies were associated with slower reaction times on a modified emotional Stroop task when the stimulus words were anthrax-related, and this effect was moderated by a manipulation of perceived control. Specifically, individuals with low perceived control over the health threat had greater attentional bias of anthrax infection, independent of related variables such as anxiety.