Anxiety sensitivity and its impact on pain experiences and conditions: a state of the art

This paper serves as an introduction to the special issue of Cognitive Behaviour Therapy devoted to the topic of anxiety sensitivity (AS) and its impact on pain experiences and conditions. We provide a historical overview of relevant cognitive behavioural models of chronic pain, summarize recent models incorporating the AS construct, and introduce the papers in the special issue. These papers are organized into two sets--basic laboratory-based investigations and relatively more applied studies. We attempt to highlight some of the most important findings from each of these investigations and studies, in turn. Then, we consider several important conclusions derived from the set of special issue papers and the implications of these for the practice of cognitive-behavioural interventions with pain populations. Finally, we make several suggestions for directions for future investigations in this burgeoning area of cognitive behavioural research and practice.     

Tendency to Catastrophize Somatic Sensations: Pain Catastrophizing and Anxiety Sensitivity in Predicting Headache

General catastrophic thinking styles about uncomfortable bodily sensations may predispose the development of common health pathologies, such as persistent headache. The purpose of this research was to explore the relationships between the Pain Catastrophizing (PC) Scale and Anxiety Sensitivity (AS) Index, which measure tendencies to catastrophize pain‐ and anxiety‐related somatic sensations, respectively. A non‐clinical sample completed the PC Scale, AS Index, and health outcome questionnaires regarding headache (n = 1018). Results revealed that: (i) AS and PC are empirically separate constructs; (ii) the overlap between PC and AS lies within the domain of fearing physical catastrophe; (iii) AS independently predicts weekly headache, headache pain intensity, and the number of a wide range of physical symptoms associated with headache; and (iv) PC independently predicts the presence of weekly headache. Limitations and implications of this research, as well as recommendations for future research 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.     

Understanding the relationship between attachment style, pain appraisal and illness behavior in women

Insecure attachment has been hypothesized to be an important factor for understanding the experience of pain. Considering the Attachment-Diathesis Model of Chronic Pain developed by Meredith, Ownsworth, and Strong (2008), this cross-sectional study examines the relationship between attachment style, pain appraisal, and illness behavior. Two hundred healthy women recruited from community contexts completed a battery of self-report measures including the Short-form McGill Pain Questionnaire, Pain Catastrophizing Scale, Pain Anxiety Symptoms Scale-20, Pain Vigilance and Awareness Questionnaire, Illness Attitude Scales, Beck Anxiety Inventory, Beck Depression Inventory, and the Experiences in Close Relationships Questionnaire-Revised. The results showed that attachment anxiety was significantly correlated with pain catastrophizing, pain-related fear, depression, and illness behavior. However, attachment anxiety and avoidance were not associated with pain intensity. Attachment anxiety moderated the relationship between pain catastrophizing and illness behavior, and between pain hypervigilance and illness behavior. Pain catastrophizing and pain-related fear partially mediated the effect of attachment anxiety on illness behavior. The findings highlight potential contributions of attachment style and pain appraisal for explaining illness behavior. This study supports earlier reports and suggests the usefulness of assessing attachment style for early identification of people who might exhibit a high risk of dysfunctional responses to pain. Our findings also suggest that increasing people's insight about their attachment style and modifying some associated dysfunctional responses may be important in the treatment of chronic pain.     

Anxiety sensitivity, body vigilance and fear of pain

The aim of the present study was to investigate the role of anxiety sensitivity (AS) as a factor relevant to pain and pain persistence. Two studies were conducted to examine the relationship between AS, body vigilance and the experience of pain in non-clinical samples. Study 1 investigated the relationship between AS and body vigilance that was operationalized by the detection latency for innocuous electrical stimuli; trait anxiety and neuroticism were also included as covariates. Results indicated that the high AS group (N=69) presented shorter detection latency than the low AS group (N=70); neuroticism and trait anxiety did not have significant effects on detection latency. Using another sample, Study 2 investigated the relationship between AS, body vigilance, pain tolerance, catastrophizing, and self-reported distress and pain during a cold pressor task. Neuroticism, trait anxiety and fear of pain were included as covariates. Results showed significant differences between high- (N=66) and low- (N=69) AS groups in body vigilance, catastrophizing and tolerance. The covariates neuroticism, trait anxiety and fear of pain did not have any significant effects. No significant differences were found in pain and distress ratings. Results from both studies support the importance of AS in body vigilance and the experience of pain. The theoretical, preventive and clinical implications of these findings are discussed.     

疼痛恐惧的形成及其对疼痛知觉的影响

脑岛、杏仁核是疼痛恐惧形成的重要神经网络中心。疼痛恐惧增强了慢性疼痛患者的疼痛知觉体验, 进而加剧抑郁、焦虑情绪和功能损伤程度。脑岛、杏仁核、前额皮层和前扣带回是疼痛恐惧影响疼痛知觉的重要神经基础。通过认知方法干预疼痛恐惧可以改善患者的抑郁、焦虑情绪, 减少功能损伤。未来研究应拓展疼痛恐惧的测量工具, 采用功能磁共振成像技术进一步揭示疼痛恐惧影响慢性疼痛患者疼痛知觉的神经机制。     

The impact of experiential avoidance on the relations between illness representations,pain catastrophising and pain interference in chronic pain

Objective: The aim of this study was to examine the effects of experiential avoidance (EA) on the indirect relationship of chronic pain patients’ illness representations to pain interference, through pain catastrophising

Design and main outcome measure: The sample consisted of 162 patients diagnosed with an arthritis-related or a musculoskeletal disorder. The effects of EA on the pathway between illness representations, pain catastrophising and pain interference were examined with PROCESS, a computational tool for SPSS

Results: After controlling for patient and illness-related variables and pain severity, the ‘illness representations–pain catastrophising–pain interference’ pathway was interrupted at the higher levels of EA. The reason was that, at the high levels of EA, either the relation of illness representations to pain catastrophising or the relation of pain catastrophising to pain interference was not statistically significant.

Conclusion: The findings indicate that EA is not a generalised negative response to highly aversive conditions, at least as far as the factors examined in this study are concerned. EA may rather reflect a coping reaction, the impact of which depends on its specific interactions with the other aspects of the self-regulation mechanism. At least in chronic pain, EA should become the focus of potential intervention only when its interaction with the illness-related self-regulation mechanism results in negative outcomes.     

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.     

疼痛恐惧相关的注意偏向及其矫正

疼痛恐惧是影响和维持慢性痛的重要因素。不同材料和被试类型情况下, 疼痛恐惧均主要作用于个体对疼痛相关信息的早期注意加工阶段, 表现为注意警觉模式。该注意模式使个体将注意维持在疼痛上, 从而干扰了对非疼信息的注意能力。矫正疼痛恐惧相关注意偏向可以改善疼痛体验。未来研究应采用更具生态效度的任务测量疼痛恐惧相关的注意偏向及其神经基础, 进一步考察矫正疼痛恐惧相关注意偏向能否改善慢痛患者的忧郁和功能丧失等问题。     

Treatments Addressing Pain-Related Fear and Anxiety in Patients with Chronic Musculoskeletal Pain: A Preliminary Review

Abstract

This review covers the current cognitive behavioural treatments available to address fear-avoidance beliefs in patients with chronic musculoskeletal pain (CMP). Four types of treatment protocols were identified for inclusion in the review: (a) graded in vivo exposure (GivE); (b) graded activity (GA); (c) acceptance and commitment therapy (ACT); and (d) mixed cognitive behavioural protocols. Most of the research suggests that GivE and ACT result in the best outcomes for treating fear-avoidance beliefs in patients with CMP. There is also a readily apparent paucity of research from North America; indeed, most of the available studies were conducted in the Netherlands and Scandinavia. This relative absence of North American research raises potentially important questions about the role of compensation status and access to care, which differ between countries, on treatment outcome. Implications and directions for future research are discussed.     

The moderating role of attachment insecurities in the association between social and physical pain

We examined the effects of social exclusion and attachment insecurities (anxiety, avoidance) on physical pain sensitivity, hypothesizing that anxiety would predict greater physical pain sensitivity only following social exclusion. Participants were either included in or excluded from a computer-based ball-tossing game and then completed a coldpressor task. Anxious men showed greater physical pain sensitivity when excluded, but not when included. Moreover, individuals (men and women) high on both anxiety and avoidance showed greater physical pain sensitivity when excluded, but not when included. Conclusions: Anxious individuals’ heightened physical pain sensitivity following exclusion is a manifestation of hyperactivation of their attachment systems, and when threatened, avoidant individuals who are also high in anxiety are less successful in deactivating their attachment systems.     

Assessing the Relationship Between Cold Pressor Pain Responses and Dimensions of the Anxiety Sensitivity Profile in Healthy Men and Women

Anxiety sensitivity (AS) has been shown previously to be an important factor in the perception and experience of experimentally induced pain within healthy adults. The aim of the current study was to extend this research by: (i) using the Anxiety Sensitivity Profile (ASP) as an alternative measure of AS; (ii) examining whether different coping instructions affect pain reports; and (iii) investigating potential differences between men and women. Participants were 50 healthy adults (23 males, 27 females) who were required to complete 2 versions of the cold pressor pain task; one version required the use of control instructions, whereas the other made use of acceptance‐based instructions. Although the coping instructions were found to affect pain thresholds (acceptance resulted in lower thresholds), a similar pattern of correlations were found between the pain indexes and AS under both conditions. Of the ASP subscales, the gastrointestinal and cognitive concerns components were found to be the most strongly related to pain experiences. When the analysis was conducted separately for each sex, the ASP scales were related to the self‐report measures of pain in women, whereas they were related to the behavioural measures of pain in men. These results not only confirm that AS is associated with experimental pain, but that there may be sex differences in this relationship.     

Health care utilisation in patients with non-cardiac chest pain: A longitudinal analysis of chest pain,anxiety and interoceptive fear

Chest pain can be a frightening experience that leads many to seek medical evaluation. The symptom results in costly health care utilisation. Over half of patients referred for cardiac evaluations of chest pain do not obtain definitive medical explanations for their symptoms; these cases are described as non-cardiac chest pain (NCCP). Some patients with NCCP are not reassured after being informed their chest pain is non-cardiac in origin and seek repeated medical evaluation. Co-morbid anxiety and mood disorders often coexist with NCCP and are associated with health care utilisation. The current study examined chest pain, general anxiety, interoceptive fear and health care utilisation in a sample of 196 chest pain patients near the time of cardiac evaluation (Time 1), and 70 of these patients one year later (Time 2). Results indicate that anxiety and interoceptive fear were significantly associated with health care utilisation at Time 1, and only interoceptive fear (at Time 1) predicted health care utilisation at Time 2. This study develops research in this area by examining the relation of anxiety and health care utilisation longitudinally in patients with NCCP.     

The development of the multidimensional locus of pain control questionnaire (MLPC): Factor structure,reliability, and validity

This study was conducted to develop a comprehensive Multidimensional Locus of Pain Control questionnaire (MLPC) and to examine how locus of pain control is related to pain appraisals, pain coping strategies, and adjustment to chronic pain. Subjects were 170 chronic headache patients. By means of factor analysis, four subscales were derived: an Internal, a Chance, a Physician, and a Medication locus of pain control orientation scale. The reliability and validity of the subscales appeared to be satisfactory. The results of the present study indicate that the locus of pain control orientation is significantly related to pain appraisals such as perceived pain control and catastrophizing and, to a lesser degree, to coping strategies as measured by the Coping Strategies Questionnaire (CSQ). However, almost no relationship was observed between locus of pain control and adjustment to pain. Further research with the MLPC in different chronic pain populations is warranted in order to investigate whether the results found in this study can be generalized to chronic pain patients in general.     

Anticipatory Processing and Post‐Event Processing in Social Anxiety Disorder: An Update on the Literature

Two repetitive thinking processes that have been proposed in prominent maintenance models of social anxiety disorder (SAD) are anticipatory processing and post‐event processing. Research into these two processes has steadily increased over the last 20 years. This review highlights the main lines of existing research on anticipatory processing and post‐event processing, including studies on the nature of these processes, their association with social anxiety, the predictors, and consequences of these processes, as well as how these processes respond to treatments for SAD. The review also highlights some of the conceptual and methodological issues that have prevented the literature on anticipatory processing and post‐event processing from being more integrated and focused. Finally, the review draws together some new directions in terms of theory and research to further advance the field.     

Anxiety sensitivity and intolerance of uncertainty: Evidence of incremental specificity in relation to health anxiety

Anxiety sensitivity (AS) reflects the fear of arousal-related sensations and intolerance of uncertainty (IU) represents the dispositional fear of the unknown. Within cognitive–behavioral models, AS and IU are individual difference variables considered central to the phenomenology of health anxiety. However, prior studies have cast doubt on whether both variables incrementally contribute to our understanding of health anxiety. Addressing limitations of these prior studies, the present study examined the incremental specificity of AS and IU as these two variables relate to health anxiety in a large medically healthy sample of community adults (N = 474). Both AS and IU incrementally contributed to the concurrent prediction of health anxiety beyond both negative affect and one another. However, within these analyses, the physical dimension of AS and the inhibitory dimension of IU were the only AS and IU dimensions to evidence incremental specificity in relation to health anxiety.     

The potential mediating role of anxiety sensitivity in the impact of mindfulness training on anxiety and depression severity and impairment: A randomized controlled trial

The benefits of mindfulness-based interventions to alleviate anxiety and depression have been supported by many studies. Given the effectiveness of mindfulness-based interventions on anxiety and depression, the underlying mechanisms need to be explored. Using a randomized waitlist-controlled design, this study investigated whether anxiety sensitivity was a potential mechanism for the impact of mindfulness training on anxiety and depression. Participants with high psychological distress were randomly assigned to an eight-week mindfulness intervention (N = 35) or a wait-list control group (N = 34). Before and after the intervention or corresponding waitlist period, participants completed measures of anxiety and depression severity and impairment and anxiety sensitivity. Separate mixed ANOVA demonstrated significant group (intervention vs. control group) × time (pre- vs. post-test) interactions for anxiety sensitivity and overall anxiety severity and impairment and marginally significant interaction for overall depression severity and impairment. Moreover, simple mediation models showed that reductions of anxiety sensitivity from pre- to post-test mediated the impact of mindfulness training on changes in anxiety and depression severity and impairment. The findings suggest that anxiety sensitivity is a potential mechanism underlying the effect of mindfulness training on anxiety and depression, which provides a new perspective for the study of processes of change of mindfulness-based interventions.     

大学生评价恐惧在自尊与社交焦虑间的中介效应分析

为探讨评价恐惧在自尊与社交焦虑间的作用,本研究采用正向评价恐惧量表、负向评价恐惧量表、自尊量表、社交互动焦虑量表,以大学生作为研究对象进行问卷调查,得到655份有效问卷。研究结果表明:(1)正向评价恐惧量表在本研究大学生样本中具有良好的信、效度。(2)正向评价恐惧、负向评价恐惧在自尊与社交焦虑间起着部分中介作用,中介效应值为47.17%,即自尊一方面直接影响社交焦虑,另一方面通过负向评价恐惧、正向评价恐惧影响社交焦虑。