Cognitive, behavioral, and physiological reactivity to chronic itching: Analogies to chronic pain

It is well-known that cognitive, behavioral, and physiological reactivity to pain, such as catastrophizing, avoidance of activity, and increased physiological responses, can unfavorably affect long-term outcomes in patients with chronic pain. In line with similarities between the psychophysiology of pain and itching, corresponding mechanisms may be relevant for the maintenance of chronic itching. The goal of this study was to examine the role of self-reported cognitive, behavioral, and physiological reactivity factors on itching-related outcomes in 235 patients with chronic skin diseases suffering from chronic itching. Sequential regression analyses indicate that all 3 reactivity systems predicted itching-related outcomes. Specifically, more catastrophizing, higher levels of avoidance of activity, and heightened self-reported physiological reactivity predicted more itching, more scratching, and a reduced disease-related quality of life. The results suggest that a psychological model as described for chronic pain is a useful starting point for study of the maintaining mechanisms of chronic itching.     

Understanding catastrophizing from a misdirected problem-solving perspective

Objectives. The aim is to explore pain catastrophizing from a problem‐solving perspective. The links between catastrophizing, problem framing, and problem‐solving behaviour are examined through two possible models of mediation as inferred by two contemporary and complementary theoretical models, the misdirected problem solving model ( Eccleston & Crombez, 2007 ) and the fear‐anxiety‐avoidance model ( Asmundson, Norton, & Vlaeyen, 2004 ). Design. In this prospective study, a general population sample (n= 173) with perceived problems with spinal pain filled out questionnaires twice; catastrophizing and problem framing were assessed on the first occasion and health care seeking (as a proxy for medically oriented problem solving) was assessed 7 months later. Methods. Two different approaches were used to explore whether the data supported any of the proposed models of mediation. First, multiple regressions were used according to traditional recommendations for mediation analyses. Second, a bootstrapping method (n= 1000 bootstrap resamples) was used to explore the significance of the indirect effects in both possible models of mediation. Results. The results verified the concepts included in the misdirected problem solving model. However, the direction of the relations was more in line with the fear‐anxiety‐avoidance model. More specifically, the mediation analyses provided support for viewing catastrophizing as a mediator of the relation between biomedical problem framing and medically oriented problem‐solving behaviour. Conclusion. These findings provide support for viewing catastrophizing from a problem‐solving perspective and imply a need to examine and address problem framing and catastrophizing in back pain patients.     

The effect of laboratory-induced depressed mood state on responses to pain

Some researchers have suggested that a depressed mood state is associated with alterations in responses to pain. The authors examined cognitive, behavioral, and affective responses of 75 randomly assigned participants to depressed, neutral, or elated mood state induction conditions and subjected them to the cold-pressor task. Because they were unsuccessful in inducing elated moods, the authors used only the data for the depressed and neutral states as they measured pain threshold, tolerance, and unpleasantness during the test. After the task, the authors measured sensory, affective, and evaluative responses to the cold-pressor pain, as well as the participants' catastrophizing ideation about the painful procedure. The depressed mood state group, compared with the neutral group, had significantly lower cold-pressor tolerance times and higher pain catastrophizing scores. These results support previous findings that a depressed mood state may be associated with alterations in some pain responses.     

Functional disability in nonspecific low back pain: The role of pain-related fear and problem-solving skills

Previous studies have shown that pain disability in chronic back pain patients is closely associated with pain-related fear and avoidance. This study was aimed at replicating this finding in a sample of low back pain (LBP) patients with a new episode of sick leave. In addition, the supplemental value of problem solving in predicting pain disability was examined. It was further hypothesized that problem solving would moderate the effects of daily stress on pain disability. The results were partly as predicted. Pain-related fear, pain intensity, pain catastrophizing, daily stress, and problem solving were found to be individually related to functional disability, of which pain intensity and pain catastrophizing were the strongest predictors. Problem solving neither added predictive value regarding pain disability, nor could the moderating role of problem solving be confirmed. Surprisingly, and in disagreement with previous findings, pain intensity was found to be closely related to disability in this sample of LBP patients. This study was supported by Grant No. 940-31-004 of the Council for Medical and Health Research of the Netherlands (MW-NWO).     

Age of onset and behavioral manifestations in Huntington's disease: An Enroll‐HD cohort analysis

Huntington's disease is associated with motor, cognitive and behavioral dysfunction. Behavioral symptoms may present before, after, or simultaneously with clinical disease manifestation. The relationship between age of onset and behavioral symptom presentation and severity was explored using the Enroll‐HD database. Manifest individuals (n = 4469) were initially divided into three groups for preliminary analysis: early onset (<30 years; n = 479); mid‐adult onset (30‐59 years; n = 3478); and late onset (>59 years; n = 512). Incidence of behavioral symptoms reported at onset was highest in those with early onset symptoms at 26% (n = 126), compared with 19% (n = 678) for mid‐adult onset and 11% (n = 56) for late onset (P < 0.0001). Refined analysis, looking across the continuum of ages rather than between categorical subgroups found that a one‐year increase in age of onset was associated with a 5.6% decrease in the odds of behavioral symptoms being retrospectively reported as the presenting symptom (P < 0.0001). By the time of study enrollment, the odds of reporting severe behavioral symptoms decreased by 5.5% for each one‐year increase in reported age of onset. Exploring environmental, genetic and epigenetic factors that affect age of onset and further characterizing types and severity of behavioral symptoms may improve treatment and understanding of Huntington's disease's impact on affected individuals.     

Pain catastrophizing,physiological indexes,and chronic pain severity: tests of mediation and moderation models

Catastrophizing about pain is related to elevated pain severity and poor adjustment among chronic pain patients, but few physiological mechanisms by which pain catastrophizing maintains and exacerbates pain have been explored. We hypothesized that resting levels of lower paraspinal muscle tension and/or lower paraspinal and cardiovascular reactivity to emotional arousal may: (a) mediate links between pain catastrophizing and chronic pain intensity; (b) moderate these links such that only patients described by certain combinations of pain catastrophizing and physiological indexes would report pronounced chronic pain. Chronic low back pain patients (N = 97) participated in anger recall and sadness recall interviews while lower paraspinal and trapezius EMG and systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were recorded. Mediation models were not supported. However, pain catastrophizing significantly interacted with resting lower paraspinal muscle tension to predict pain severity such that high catastrophizers with high resting lower paraspinal tension reported the greatest pain. Pain catastrophizing also interacted with SBP, DBP and HR reactivity to affect pain such that high catastrophizers who showed low cardiovascular reactivity to the interviews reported the greatest pain. Results support a multi-variable profile approach to identifying pain catastrophizers at greatest risk for pain severity by virtue of resting muscle tension and cardiovascular stress function.     

Acceptance of pain,self‐compassion and psychopathology: Using the Chronic Pain Acceptance Questionnaire to identify patients' subgroups

The present study explores whether specific subgroups of patients could be identified based on Chronic Pain Acceptance Questionnaire scores. A battery of self‐report questionnaire was used to assess acceptance of pain, self‐compassion and psychopathology in 103 participants with chronic pain, from Portuguese health care units. K‐Means cluster were performed and the results supported three subgroups of patients (low acceptance subgroup; high acceptance subgroup; intermediate subgroup with activity engagement near to the mean and low willingness to pain). One‐way ANOVA's showed that the three subgroups identified differed significantly from each other on psychopathology and self‐compassion. Results indicated that the intermediate subgroup presented less depression and stress, compared with the low acceptance subgroup. In what concerns self‐compassion, the low acceptance subgroup reported higher self‐judgment, isolation and over identification, compared with the intermediate subgroup. These subgroups also differed from each other in common humanity and mindfulness. Implications and clinical utility of the results were discussed, suggesting the increase of willingness to pain as an important key in chronic pain interventions. Copyright © 2010 John Wiley & Sons, Ltd. Key Practitioner Message: ? Findings suggest the buffer effect of activity engagement in chronic pain on psychopathology; ? The expressive relation between activity engagement and self‐compassion in chronic pain; ? The presence of an intermediate subgroup of patients suggests that the increase of willingness to pain may add unique benefits in the treatment of chronic pain.     

Pain Catastrophizing Mediates the Relationship Between Trait Happiness and Depressive Symptoms in Individuals with Current Pain

Relatively little research has examined the contributions of pain‐specific factors, such as pain intensity, and normative factors, such as positive emotions, in predicting depression. This study characterized the independent contributions of pain intensity, pain catastrophizing, and trait happiness to depressive symptoms in 70 volunteers across three groups: two groups with current low back pain and those in a methadone maintenance treatment program. Results suggested no direct relationships between pain and either trait happiness or depressive symptoms, but participants reporting higher levels of trait happiness tended to report lower levels of depressive symptomatology, an effect mediated by lower levels of pain catastrophizing. Though unrelated to pain, trait happiness may alter pain‐relevant outcomes through reduced catastrophizing levels.     

Relation of cognitive coping and catastrophizing to acute pain and analgesic use following breast cancer surgery

This study investigated the relation of cognitive coping and catastrophizing to acute postoperative pain and analgesic use. Fifty-nine women who had just undergone breast cancer surgery rated their pain on 3 consecutive days and completed a self-report measure of cognitive coping and catastrophizing prior to hospital discharge. Analgesic use over the 3-day period was tabulated from pharmacy records. Based on prior research, it was hypothesized that increased catastrophizing and decreased use of cognitive coping strategies would be associated with greater pain and analgesic use. Results partially confirmed these hypotheses. Catastrophizing, but not cognitive coping, was associated with individual differences in pain intensity and analgesic use. Additional analyses indicated that age was a significant predictor of both catastrophizing and postoperative pain. Specifically, younger patients were more likely to catastrophize and to report increased postoperative pain. Theoretical and clinical implications of these findings are discussed.     

“FastSchool”: A single session of an interprofessional pain management program for chronic pain patients inspired by cognitive behavioral therapy

ObjectivesMultidisciplinary approaches to treating chronic pain have been proven effective. Currently, chronic pain patients face lengthy waitlists in pain medicine departments. To overcome this problem, we developed the “FastSchool” program to educate patients about pain management and treatment. In this study, we evaluated the benefit of a “FastSchool” session on pain and catastrophizing in chronic pain patients.MethodsIncluded patients had chronic non-cancer pain, no more than 2 visits to a pain medicine department. Patients attended a single 3-hour session, conducted by an interprofessional team. Four topics were addressed: chronic pain mechanisms, pharmacological therapies, physical activity, and the management of analgesics. Patients completed questionnaires at baseline and at 3 months post-session to assess pain interference, pain intensity, and catastrophizing.ResultsThe study population included 88 patients; 71 completed the follow-up questionnaires. Pain interference (p = 0.002), average pain intensity (p = 0.013), and catastrophizing (p < 0.001) decreased 3 months after FastSchool. At M3, 35 % of patients felt their pain had improved based on the Patient Global Impression of Change.ConclusionFastSchool, an innovative short-term educational program inspired by cognitive behavioral therapy, showed positive results in reducing pain impact.Practice implicationsImplementation of FastSchool in pain medicine departments would reduce waitlist times for non-pharmacological treatment.     

How do cancer patients manage unattainable personal goals and regulate their emotions/

Objectives This article addressed the role of goal adjustment (i.e. disengagement from unattainable goals and reengagement in alternative goals) and cognitive emotion‐regulation strategies (i.e. rumination, catastrophizing, positive refocusing) in cancer patients' psychological well‐being. We expected that patients who are better able to disengage from unattainable goals, identify alternative goals, and regulate their emotions by positive refocusing and not engaging in rumination and catastrophizing would experience less negative and more positive affect. Design In this cross‐sectional study, data were collected using a self‐report questionnaire. Methods Cancer patients (N = 108) were recruited on a psychoeducational meeting aimed to inform them about the illness and its consequences. To examine the relationships between goal adjustment, cognitive emotion‐regulation strategies, and affect, Pearson correlations were calculated and regression analyses were performed. Results Regression analyses showed that reengaging in meaningful goals and focusing on pleasant issues were significantly associated with more positive affect. Focusing on pleasant issues was also significantly associated with less negative affect, whereas rumination and catastrophizing were significantly associated with more negative affect. Conclusions Goal reengagement as well as cognitive emotion‐regulation strategies seems to play an important role in cancer patients' psychological well‐being. Health care professionals may assist patients in paying more attention to positive experiences in their daily life and in finding new meaningful goals. Techniques based on mindfulness may be used to assist cancer patients in decreasing the repetitive negative thinking about causes, meanings, and consequences of the illness and helping them to focus attention on the present moment.     

Can self-pain sensitivity quantify empathy for others' pain?

Empathy is essential for the survival of social species. In many studies, especially those with animal models, empathy for pain was evaluated by the modulation of pain sensitivity. However, the relationship between pain sensitivity and empathy for pain is not well established. Here, by performing two experiments, we aimed to investigate their relationship at both behavioral and electrophysiological levels. In Experiment 1, we characterized individual pain sensitivity using pain threshold and tolerance in a cold pressor test, self-report empathy using Interpersonal Reactivity Index, and pain-related psychological factors, including pain-related anxiety, depression, pain catastrophizing, and pain-related fear, using well-validated questionnaires. We observed that pain sensitivity was positively correlated with emotional empathy, and their relationship was mediated by pain-related anxiety, pain catastrophizing, and pain-related fear. In Experiment 2, we quantified empathy for pain using pain intensity and unpleasantness as well as event-related potentials (ERPs) in an empathy for pain task. Positive correlations were observed between pain sensitivity and psychophysiological empathic responses (i.e., the P3 component and the late positive potential in ERPs), and their relationship was mediated by pain-related fear. These results suggested that being influenced by some pain-related psychological factors, individuals with higher pain sensitivity tended to have stronger empathy for pain, manifested as stronger emotional reactions to others' pain. Our results indicated that the conventional strategy of using pain sensitivity to quantify empathy should be treated with caution, as their relationship could be disturbed by experimental manipulations or pathological modulations that could influence individual emotional states or cognitive processes.     

Cognitive processes in comorbid poor sleep and chronic pain

We examined the unique and shared contributions of pain catastrophizing, cognitive pre-sleep arousal, and somatic pre-sleep arousal, to the prediction of insomnia severity in chronic pain. Forty-eight adults with chronic pain completed self-report measures of these study variables, health, and mood. Hierarchical regression showed that pain catastrophizing accounted for unique variance in insomnia severity, independent of pain intensity, depression, restless legs symptoms, and demographics. However, when cognitive and somatic pre-sleep arousal were also taken into account, the significance of cognitive pre-sleep arousal rendered pain catastrophizing non-significant. We identify research and clinical implications of this study.     

Sympathetic pain? A role of poor parasympathetic nervous system engagement in vicarious pain states

This study investigated the psychophysiological correlates of the subjective experience of vicarious pain; that is, a spontaneous experience of pain when seeing another in pain. Forty‐nine healthy, otherwise pain‐free individuals aged 18–55 years completed empathy and anxiety questionnaires and were classified into three groups: vicarious responders with high anxiety (n = 11), vicarious responders with low anxiety (n = 22), and nonresponders (n = 16). Electrophysiological recordings of heart rate variability (HRV) during paced breathing and cognitive stress (serial sevens task) were completed before participants viewed short videos of athletes in states of pain or happiness, taken from Australian League Football matches. Change in beats per minute, relative to neutral scenes, were analy z ed for the first 4 s after onset of the painful or happy event. Anxious responders had lower HF‐HRV than both other groups, implicating poor parasympathetic regulation specific to states of stress. Both vicarious responder groups had elevated HR at the event onset, regardless of valence. After viewing painful injuries, nonanxious vicarious responders showed sustained HR over time, anxious responders showed HR acceleration with a peak at 3 s after the injury onset, and nonresponders showed a pattern of marked HR deceleration. These findings suggest that vicarious pain in anxious responders is associated with poorly regulated sympathetic arousal via insufficient inhibitory parasympathetic activity, whereas nonanxious persons show sustained arousal. Clearly, multiple mechanisms in the central and peripheral nervous system must play a role in vicarious pain states, and the different manifestations are likely to lead to very different behavioral consequences.     

Effects of catastrophizing on pain perception and pain modulation

The multidimensional experience of pain is thought to be partially influenced by the pain modulation system as well as by individual psychological components. Recent studies demonstrated possible common neural network mediating both domains. The present study examined the relationships between pain perception, pain modulation, and catastrophizing in healthy subjects. Forty-eight participants (29 females and 19 males) completed the pain catastrophizing scale (PCS) and underwent psychophysical tests in order to evaluate the modulation of pain, using the diffuse noxious inhibitory control (DNIC) paradigm. Contact heat pain (47.0°C applied for 1 min), which was used as the “test” stimulation, was applied before and after a physical effort that induces pain (repeated squeezing of a hand grip device), which was used as a “conditioning” stimulus. Numeric pain scale intensities (NPS, 0–10) were evaluated four times during each of two separate consecutive runs of heat stimulation. Results showed a significant positive correlation of PCS with heat pain (r = 0.48, p < 0.0005) and with muscle pain (r = 0.31, p = 0.03). In addition, significant negative correlations were found between PCS and DNIC effect (r = −0.34, p = 0.02). Moreover, once catastrophizing was entered into the regression analysis, the previously significant effect of gender was no longer found. In conclusion, individuals with high catastrophizing levels demonstrated higher pain intensities and lower effects of DNIC indicating that catastrophizing might have a significant impact on pain perception via an association with pain modulation.     

The Cognitive and Behavioral Treatment of PTSD,What Is Known and What Is Known to Be Unknown: How Not to Fall Into the Practice Gap

[Clin Psychol Sci Prac 17: 134–143, 2010] Posttraumatic stress disorder is a serious potential consequence of suffering severe trauma. Effective treatments exist, and these include both cognitive and behavioral, mainly exposure‐based treatments. How clinical practice can be guided by the research evidence is a difficult question given the research‐practice gap, and clinicians have a duty of care to provide the optimum treatment for their individual patients. Such duty includes not only taking into account the evidence from clinical trials but also a recognition that there is considerable potential heterogeneity in trauma patients. Factors that influence which treatment is recommended and where future development lies include the following: any potential advantage one treatment has when there is equivalent efficacy; the persistence of physical injury, pain, and disability; presence of medical illness; persistent or long‐term exposure to traumatic stress; comorbidity of psychological disorders; suicide risk and exposure to aversive psychosocial environments. Lastly, the development of positive psychology may offer further treatment options.     

Targeting emotional regulation using an Internet-delivered psychological intervention for cancer survivors: A randomized controlled trial

Objectives

This trial assessed the efficacy of an emotion-focused, modular, Internet-delivered adaptation of the Unified Protocol (UP) in improving cancer survivors' emotion regulation strategies.

Design

A two-arm randomized controlled trial (1:1) was used to compare the efficacy of two Internet-based interventions: UP-adapted CanCope Mind (CM) and lifestyle-focused active control CanCope Lifestyle (CL).

Methods

N = 224 cancer survivors randomized to CM or CL were assessed at baseline, between-modules, at post-intervention and 3-month follow-up on emotion regulation outcomes targeted by each CM module (Module 1: beliefs about emotions; Module 2: mindfulness; Module 3: cognitive reappraisal skills, catastrophizing, refocus on planning; Module 4: experiential avoidance). Primary analyses were intention-to-treat linear regressions using Fisher randomization tests for p-values and intervals were used to compare groups with standardized mean difference (SMD) effect sizes.

Results

CanCope Mind participants (n = 61 completers) experienced moderate-to-large improvements (SMDs from .44–.88) across all outcomes at post-intervention. CM's effects were larger than CL's (n = 75 completers) immediately post-intervention and at 3-month follow-up for beliefs about emotions, mindfulness, cognitive reappraisals and experiential avoidance (all p's < .05). CM experienced greater improvements in catastrophizing immediately post-intervention, with a trending effect at follow-up. However, we could not reject the null hypothesis of identical between-group effects for refocusing on planning both immediately post-intervention and at follow-up. Exploratory analyses revealed inconsistent between-module effects.

Conclusions

In its entirety, CM is a promising intervention for improving and maintaining cancer survivors' adaptive emotion regulation, especially for mindfulness and experiential avoidance. This may have important clinical implications for promoting cancer survivors’ emotional functioning and general well-being.     

Developmental Changes in Children's Cognition to Stressful and Painful Situations

Recent research suggests that some adults spontaneously employvarious types of cognitive coping strategies in stressful situations.Subjects who employ cognitive coping strategies typically reportless pain and stress than subjects who focus on or exaggeratethe negative aspects of the situation ("catastrophizers"). Thepurpose of the present investigation was to determine what typesof cognitions (both coping and catastrophizing) children reportin response to two imagined and one recent personal stressor,and how these cognitions relate to age, trait anxiety, and gender.The results indicated that the number of copers increased significantlywith age. Positive self-talk was the most frequently reportedcognitive coping strategy and its use significantly increasedwith age. Additionally, the total number of different typesof strategies used increased with age. Copers reported significantlyless trait anxiety than catastrophizers. There were no sex differencesin the prevalence of coping and catastrophizing. Despite thefact that coping increased with age, catastrophizing still occurredat a relatively high rate. Catastrophizing most frequently tookthe form of focusing on negative affect. Discussion focusedon the significance of these findings and implications for futureresearch.     

Understanding Pain and Depression in Back Pain: the Role of Catastrophizing,Help-/Hopelessness,and Thought Suppression as Potential Mediators

Purpose

The cognitive mediation hypothesis describes the influence of psychological factors on the relationship between pain and depression such as cognitions of catastrophizing and help-/hopelessness. More recent research also emphasizes the role of suppression of negative thoughts and experiences such as pain. However, there is little research investigating direct and indirect effects of these contrasting cognitions.

Method

A total of 164 acute and sub-acute non-specific back pain patients participated in this study. Pain intensity, depression, and pain-related cognitions were measured using questionnaires, such as the Beck Depression Inventory and the Kiel Pain Inventory. Data were analyzed using structural equation modeling.

Results

The results of the path analysis support the hypothesis that cognitive coping strategies have a mediating effect on pain and depression. Consistent with previous research, we found that pain had no direct relation with depression. Help-/hopelessness had a direct path to depression, whereas catastrophizing had an indirect effect via increased help-/hopelessness. The current results also indicate that thought suppression mediated the relationship between pain and depression via both direct and indirect effects.

Conclusion

Cognitive mediators, such as help-/hopelessness, catastrophizing, and thought suppression, have a significant impact on depression in patients with acute and sub-acute back pain. The current results may aid in the optimization of treatments for these patients by focusing attention toward the modification of dysfunctional cognitive pain-coping strategies.

     

Cognitive Mediators of Change in Physical Functioning in Response to a Multifaceted Intervention for Managing Osteoarthritis

Purpose

Although non-pharmacological interventions have been shown to improve physical functioning in individuals with osteoarthritis (OA), the mechanisms by which this occurs are often unclear. This study assessed whether changes in arthritis self-efficacy, perceived pain control, and pain catastrophizing mediated changes in physical functioning following an osteoarthritis intervention involving weight management, physical activity, and cognitive-behavioral pain management.

Method

Three hundred Veteran patients of 30 primary care providers with knee and/or hip OA were cluster randomized to an OA intervention group or usual care. The OA intervention included a 12-month phone-based patient behavioral protocol (weight management, physical activity, and cognitive-behavioral pain management) plus patient-specific OA treatment recommendations delivered to primary care providers.

Results

Using linear mixed models adjusted for provider clustering, we observed that baseline to 6-month changes in arthritis self-efficacy and pain control partially mediated baseline to 12-month physical functioning improvements for the intervention group; catastrophizing did not.

Conclusion

Findings of a mediating role of arthritis self-efficacy and pain control in intervention-related functional changes are consistent with hypotheses and align with theoretical assertions of the role of cognitions in cognitive and behavioral interventions for chronic pain. However, contrary to hypotheses, catastrophizing was not found to be a mediator of these changes.