Attentional bias and chronic pain: Where to go from here?

Abstract

Attentional bias (AB), or selective attention for information related to the emotional concerns of patients, is an ubiquitous and well-validated phenomenon in many forms of psychopathology [1]. Also patients with chronic pain display an AB towards pain-related information, although it is not as robust as is often assumed [5,15]. Despite extant research several challenges remain, and, there is a strong need for systematic investigations in large samples [5].Sharpe and her group have taken up some of these challenges. They started a systematic research program related to three key questions: (1) "Does AB exist?", (2) "Does AB matter?", and (3) "What can we do about it?" (e.g., [7,14]). Indeed, demonstrating that AB exists, is no guarantee that it is relevant for understanding and treating the variety of problems that patients with chronic pain experience. For example, AB may just be an epiphenomenon of the presence of (chronic) pain or anxiety. The study of Sharpe and colleagues in this issue addresses the "Does it matter?" question. More specifically, Sharpe and colleagues employed a well-validated AB paradigm (a dot-probe task) in a large sample of (sub-)acute low back pain (LBP) patients to investigate whether AB towards pain-related information (i.e., words related to sensory pain, affective pain, threat or disability) are predictive of pain problems becoming chronic. Results indicate that patients with LBP show only an AB towards sensory pain words, and this result was present in both the (sub-)acute and chronic pain phase. However, AB towards sensory painrelated information was not predictive of chronicity. In fact, only directing attention away (i.e., attentional avoidance) from affective pain-related information was.These findings are intriguing. They corroborate the view that AB matters in the development of chronic pain problems. However, they challenge current thinking about the role of AB in pain. Indeed, the schema-enmeshment model of pain hypothesizes exactly the opposite, i.e., that an AB towards affective pain stimuli predicts disability and the development of a chronic pain disorder [13]. Also other theoretical accounts (e.g., [4,20]), hypothesize that an AB towards pain-related information results in worse painoutcomes (e.g., disability). These hypotheses were however not confirmed in the study of Sharpe and colleagues. So, where to go from here?Evidently, there is a need for more research to replicate the findings and to explore the role of potential moderators. It may well be that a distinction has to be made between early and late stages of information processing. According to the vigilance-avoidance hypothesis AB towards pain-related information may be found early in time (≤500ms), but may reverse and become attentional avoidance later on (>500ms) [11,12]. As yet, there is no evidence for this idea [5,15].Research on attentional bias has substantially increased during the last years. In doing so, most researchers have adapted experimental paradigms and models of attentional bias from experime...

The Effect of Perceived Injustice on Appraisals of Physical Activity: An Examination of the Mediating Role of Attention Bias to Pain in a Chronic Low Back Pain Sample

“…Collectively, such findings suggest that AB toward pain may contribute to greater pain/difficulty appraisals of everyday physical activity, and may ultimately contribute to greater disability. Accordingly, these findings further attest to the critical role of modifying attention to pain within clinical interventions or its underlying cognitions that fuel AB for pain [34,47].…”

Cognitive biases in pain: an integrated functional–contextual framework

“…Clinicians may also be more effective in impacting cognitive biases for pain by targeting the meaning or the threat value of pain or increasing peoples' awareness of their personal goals by using cognitive behavioral therapy or acceptance and commitment therapy. 34,61,77,87 Finally, one may also aim to directly train people to flexibly attend, interpret, and remember pain-related information in a changing environment. 30 In addition, the current framework provides a clear imperative to investigate the interplay between cognitive biases, which can help to identify under which circumstances it is helpful to target a single bias or multiple interacting cognitive bias(es) or their underlying mechanisms of action.…”

“…These models assume that cognitive biases are maladaptive, trait-like processes, and propose that individuals who selectively attend to pain-related information (attention bias), interpret ambiguous pain and/or health relevant information as threatening (interpretation bias), and/or recall pain-related information selectively or as more negative/threatening than initially experienced (memory bias), report higher levels of pain and disability and are at increased risk for developing chronic pain. 10,11,15,16,51,56,77,87,93,94 This intuitively appealing idea has resulted in an exponential increase in research addressing the presence, antecedents, and consequences of cognitive biases in people experiencing acute and chronic pain. 10,13,17,41,51,52,67,68,78 However, results are inconsistent and puzzling, with mixed support for theoretical-driven assumptions.…”

“…10,13,17,41,51,52,67,68,78 However, results are inconsistent and puzzling, with mixed support for theoretical-driven assumptions. 12,41,67,87,88,93 The aim of this review is to (a) synthesize and discuss current knowledge on the role of cognitive biases in pain, (b) provide conceptual and methodological explanations for equivocal findings, and (c) develop an integrated functional-contextual framework for understanding the role of cognitive biases in pain. Based on this framework, we propose a new research agenda and discuss implications for clinical practice.…”

Tired of pain? Toward a better understanding of fatigue in chronic pain

“…Studies typically look only at mean performance levels, neglecting underlying processes such as shifts in motivation [6,28]. We recommend studying attention dynamics and fluctuations over task course [31,57]. Reduced physical activity in chronic pain patients is often explained by fear-avoidance beliefs [58].…”