Adult attachment variables predict depression before and after treatment for chronic pain.

The complex relationship between chronic pain and depression has long been of clinical and empirical interest. Although attachment theory has been described as a "theory of affect regulation", and has been lauded as a developmental framework for chronic pain, surprisingly little research specifically considers the links between adult attachment variables and pain-related depression. A sample of 99 participants with chronic pain of non-cancer origin was evaluated before and after pain rehabilitation. Results demonstrated that two attachment dimensions (comfort with closeness and relationship anxiety) were related to pre- and post-treatment depression. Of particular interest was the finding that comfort with closeness was the unique predictor of lower levels of post-treatment depression, usurping pain intensity and pre-treatment depression. These results are discussed in terms of clinical implications, and suggest that adult attachment theory may prove a valuable perspective in pain treatment programs.     

The relation between catastrophizing and facial responsiveness to pain

Pain catastrophizing has recently been suggested to have a social function based on a positive association observed with facial responsiveness to noxious stimulation. However, this assumption is based on studies applying nociceptive stimuli of fixed intensity, such that high catastrophizers not only displayed increased pain behavior but also rated the stimulation as being more painful. The aim of this study was to investigate the relation between catastrophizing and facial responsiveness while controlling for individual differences in pain sensitivity. The facial expression of pain was investigated in 44 young and pain-free individuals in response to painful and non-painful phasic heat stimuli. Painful temperatures were tailored to the individual sensitivity to produce moderate pain. Facial responses were videotaped and objectively examined using the Facial Action Coding System. We also assessed skin conductance activity as an autonomic indicator of pain-related responses. Catastrophizing was assessed using the Pain Catastrophizing Scale (PCS). In accordance with previous findings, subjects scoring higher on pain catastrophizing required lower thermal intensities to induce a moderately painful sensation (r=-0.40, p=0.007). However, catastrophizing did not correlate with facial responsiveness to perceptually controlled painful stimulation (r=-0.02, p=0.88). Moreover, correlation analyses revealed no significant associations between catastrophizing and skin conductance responses. The present findings provide further support for the impact of pain catastophizing on pain sensitivity. However, our finding of no relation between catastrophizing and facial responsiveness when participants are experiencing comparable psychophysical pain intensities, challenges previous assumptions that high catastrophizers display amplified pain behavior; at least in young and pain-free individuals.     

Mothers' and fathers' responses to their child's pain moderate the relationship between the child's pain catastrophizing and disability

Preliminary evidence suggests that pain catastrophizing in children may be important in understanding how parents respond to their child’s pain. However, no study has investigated whether parental responses, in turn, moderate the impact of child’s catastrophizing upon pain outcomes. The present study was designed to address this, and investigated the association of the child’s catastrophizing with different types of parental responses (ie, solicitousness, discouragement and coping promoting responses) and the extent to which parental responses moderate the association between the child’s catastrophizing and disability. Participants were 386 school children and their parents. Analyses revealed significant associations between the child’s pain catastrophizing and parental responses, but with mothers and fathers evidencing different patterns; ie, higher levels of the child’s catastrophizing were significantly associated with lower levels of solicitousness by fathers, and with higher levels of discouragement by mothers. Moderation analyses indicated that father’s solicitiousness moderated the association between catastrophizing and disability; the positive association between catastrophizing and the child’s disability was further strengthened when fathers reported low levels of solicitousness, but became less pronounced when fathers reported high levels of solicitousness. Findings also revealed a moderating impact of mothers’ and fathers’ promotion of their child’s well behaviour/coping. Specifically, the detrimental impact of child catastrophizing upon disability was less pronounced when parents reported high promotion of their child’s well behaviours/coping. The findings of the present study suggest the importance of assessing and targeting parental responses to their child’s pain to alter the adverse impact of the child’s pain catastrophizing on pain outcomes.     

Adult attachment and reports of pain in experimentally‐induced pain

Attachment theory has been proposed as a framework for understanding the development of chronic pain, with evidence supporting the overrepresentation of insecure attachment styles in chronic pain populations and links between insecure attachment and factors known to impact one's ability to cope with pain. The present study sought to extend two earlier studies exploring the relationships between adult attachment and communication of an acute pain experience, in anticipation of providing insight into individual differences in vulnerability in development of chronic pain. It was hypothesised that: (a) fearful attachment would be associated with perceptions of the pain as less intense, and (b) anxious attachment would be associated with lower pain thresholds. A convenience sample of 82 healthy adults completed self‐report measures of attachment, neuroticism, and negative affect prior to taking part in a coldpressor pain inducement task. Results demonstrated that fearful attachment was associated with lower levels of pain intensity throughout the coldpressor task. In addition, dismissing attachment was also associated with less intense pain, as well as increased coldpressor endurance (tolerance) in the presence of a known assessor. These associations were retained after controlling for measures of neuroticism, negative affect, age, and social desirability. The results of this study are consistent with the proposition that fearful and dismissing individuals tend to mask their underlying distress caused by the pain experience, potentially leading to difficulties coping with pain over time.     

Pain catastrophizing and social support in married individuals with chronic pain: the moderating role of pain duration

In the current study, 96 married chronic pain patients were recruited from the community to test hypotheses about the roles of catastrophizing and psychological distress in relation to perceived support from close others. It was expected that pain duration would moderate the relationship between catastrophizing and perceived support and between catastrophizing and psychological distress. In addition, distress was hypothesized to mediate the relationship between the pain duration-catastrophizing interaction and support. Hierarchical regression analyses showed that pain duration interacted with catastrophizing such that at shorter pain durations, pain catastrophizing was related to more perceived solicitous spouse responses; however no such relationship existed for patients with longer pain durations. In contrast, catastrophizing was significantly related to less perceived spousal support (i.e. support not specific to pain) in patients with longer durations of pain whereas no significant relationship existed for patients with shorter pain durations. Pain duration did not interact with catastrophizing in relating to psychological distress, which precluded the examination of distress as a mediator between the pain duration-catastrophizing interaction and support. Moreover, psychological distress did not significantly mediate the relationships between pain catastrophizing and perceived support. These findings are discussed in the context of cognitive-behavioral and interpersonal perspectives of pain.     

Expressive dimensions of pain catastrophizing: An observational study in adolescents with chronic pain

Investigated was the relationship between pain catastrophizing and pain intensity in adolescents suffering from chronic pain (n = 38) and the extent to which they expressed communicative pain and pain-related protective behaviours. Adolescents were observed on video performing a 2-Min Walk Test (2MWT). Behaviours were coded on videotape. The adolescents’ verbalizations about the 2MWT were also rated by their parents. Analyses revealed that higher levels of catastrophic thinking about pain were associated with higher levels of facial pain expressions and verbalizations about their pain experience, beyond the effects of age, gender, pain duration and pain intensity. Pain-related protective behaviours did not vary with the adolescents’ level of pain catastrophizing, but varied with pain intensity. The findings corroborate the functional distinctiveness of different types of pain behaviours. The results are discussed in terms of the processes linking (1) catastrophizing to communicative pain behaviours and (2) pain to pain-related protective behaviours.     

Children’s selective attention to pain and avoidance behaviour: The role of child and parental catastrophizing about pain

The present study investigated selective attention to pain in children, its implications for child avoidance behaviour, and the moderating role of dimensions comprising child and parental catastrophizing about pain (ie, rumination, magnification, and helplessness). Participants were 59 children (31 boys) aged 10-16 years and one of their parents (41 mothers). Children performed a dot-probe task in which child facial pain displays of varying pain expressiveness were presented. Child avoidance behaviour was indexed by child pain tolerance during a cold-pressor task. Children and parents completed measures of child and parent pain catastrophizing, respectively. Findings indicated that both the nature of child selective attention to pain and the impact of selective attention upon child avoidance behaviour were differentially sensitive to specific dimensions of child and parental catastrophizing. Specifically, findings showed greater tendency to shift attention away from pain faces (ie, attentional avoidance) among children reporting greater pain magnification. A similar pattern was observed in terms of parental characteristics, such that children increasingly shifted attention away from pain with increasing levels of parental rumination and helplessness. Furthermore, child attentional avoidance was associated with greater avoidance behaviour (ie, lower pain tolerance) among children reporting high levels of pain magnification and those whose parents reported greater rumination about pain. The current findings corroborate catastrophizing as a multidimensional construct that may differentially impact outcomes and attest to the importance of assessing both child and parental characteristics in relation to child pain-related attention and avoidance behaviour. Further research directions are discussed.     

The causal status of pain catastrophizing: an experimental test with healthy participants.

In the current study we report findings on the effects of experimentally induced catastrophizing about pain on expected pain, experienced pain and escape/avoidance behavior during a cold pressor task in a sample of healthy participants. It was hypothesized that increasing the level of catastrophizing would result in a higher level of expected pain, a higher level of experienced pain, and a shorter duration of ice-water immersion. Also, it was hypothesized that these relations might be stronger for participants who already catastrophized about pain prior to the experiment. The results demonstrated that despite the successful attempt to induce catastrophizing, this neither significantly affected expected pain, experienced pain, and duration of ice-water immersion, nor were these relations moderated by the pre-experimental level of catastrophizing. Although the level of catastrophizing was successfully manipulated, more similar experiments are necessary in order to give a more definite answer on the possible causal status of pain catastrophizing.     

The effects of parental presence upon the facial expression of pain: the moderating role of child pain catastrophizing

This experiment investigated the effects of child catastrophic thinking and parental presence on the facial expressions of children when experiencing pain. School children experienced pressure pain in either one of two conditions: (1) when observed by a parent (n = 53 children and their parent), or (2) when observed by an adult stranger (n = 31 children). Analyses revealed that children showed more facial pain expression in the presence of their parent than in the presence of the stranger. This effect was, however, only found for children with infrequent catastrophic thoughts about pain. Children who have frequent catastrophic thoughts expressed high pain regardless of who they believed was observing them. Results are discussed in terms of the social consequences of pain catastrophizing, and the variables contributing to the expression or suppression of pain display in children and its impact upon others.     

The influence of fear of movement and pain catastrophizing on daily pain and disability in individuals with acute whiplash injury: a daily diary study

Previous research supports the fear-avoidance model in explaining the transition from acute to chronic non-specific musculoskeletal pain. However, there is still little knowledge on when this vicious circle of pain, disability, pain catastrophizing and fear of movement starts. We performed a daily diary study in 42 patients with acute whiplash injury. Pain, disability, pain catastrophizing and fear of movement were measured on a daily basis with paper diaries for 21 consecutive days. Most participants showed a decline in pain and disability from day 1 to day 21 and this was paralleled by a decline in the fear of movement and pain catastrophizing. Multilevel analyses showed that both between and within persons, high levels of pain catastrophizing and fear of movement are associated with more pain and disability. Moreover, the fear of movement was also predictive of pain and disability on the following day. We also examined the reverse association, that is, whether the changes in pain predict changes in the next day's fear of movement and pain catastrophizing. Although for the fear of movement the model reached significance, the amount of explained variance was negligible. In conclusion, this study provides evidence that already in the early stages of whiplash-related complaints, significant associations between fear of movement and pain intensity and disability occur, and that this association may be predictive of the persistence of pain.     

The mediating role of pain catastrophizing in the relationship between presurgical anxiety and acute postsurgical pain after hysterectomy

The aim of this study was to examine the joint role of demographic, clinical, and psychological variables as predictors of acute postsurgical pain in women undergoing hysterectomy due to benign disorders. A consecutive sample of 203 women was assessed 24 hours before (T1) and 48 hours after (T2) surgery. Baseline pain and predictors were assessed at T1 and postsurgical pain and analgesic consumption at T2. Several factors distinguished women who had no or mild pain after surgery from those who had moderate to severe pain, with the latter being younger, having more presurgical pain, and showing a less favorable psychological profile. Younger age (odds ratio [OR] = 0.90, P < .001), presurgical pain (OR = 2.50, P <.05), pain due to other causes (OR = 4.39, P = .001), and pain catastrophizing (OR = 3.37, P = .001) emerged as the main predictors of pain severity at T2 in multivariate logistic regression. This was confirmed in hierarchical linear regression (β = −0.187, P < .05; β = 0.146, P < .05; β = 0.136, P < .05; β = 0.245, P < .01, respectively). Presurgical anxiety also predicted pain intensity at T2. Findings revealed an integrative heuristic model that accounts for the joint influence of demographic, clinical, and psychological factors on postsurgical pain intensity and severity. In further mediation analysis, pain catastrophizing emerged as a full mediator between presurgical anxiety and postsurgical pain intensity. The potential clinical implications for understanding, evaluating, and intervening in postsurgical pain are discussed.     

Do fundamental fears differentially contribute to pain-related fear and pain catastrophizing? An evaluation of the sensitivity index

Three fundamental fears - anxiety sensitivity (AS), injury/illness sensitivity (IS) and fear of negative evaluation (FNE) - have been proposed to underlie common fears and psychopathological conditions. In pain research, the relation between AS and (chronic) pain processes was the subject of several studies, whereas the possible role of IS has been ignored. The current research examines the role of IS with respect to various pain-related variables in two studies. In the first study, 192 healthy college students completed the Sensitivity Index (SI; a composite measure assessing the three fundamental fears) and various pain-related questionnaires. In a second study, 60 students out of the original sample took part in a pain induction procedure and completed the SI as well. We first examined the properties of the SI. Factor analysis on the SI replicated the proposed factor structure [Taylor S. The structure of fundamental fears, J Behav Ther Exp Psychiat 1993;24:289-99]. However, some items of the ASI did show problematic loadings and were therefore excluded in subsequent analyses. The main hypothesis of the current study states that IS is a stronger predictor than AS of pain catastrophizing and fear of pain as assessed by self-report measures, and of pain tolerance and anticipatory fear of pain as assessed in a pain induction study. This hypothesis could be confirmed for all variables, except for pain tolerance, which was not predicted by any of the three fundamental fears. The current study can be considered as an impetus for devoting attention to IS in future pain research.     

Parental catastrophizing about child's pain and its relationship with activity restriction: the mediating role of parental distress

Recent research has demonstrated that parental behaviors have an important impact upon child and adolescent pain outcomes. At present, however, we do not know which parents engage in particular behaviors and why. In 2 studies, the impact of parental catastrophizing about their child’s pain upon parental tendency to stop their child’s pain-inducing activity was investigated. Further, the mediating role of parental distress was explored. In study 1, a sample of schoolchildren (n = 62; M = 12.48 years; SD = 1.72) took part in a cold-pressor task. In study 2, a clinical sample of adolescents with chronic pain (n = 36; M = 15.68 years; SD = 1.85) performed a 2-min walking task designed as a pain-inducing activity. In both studies, the accompanying parent was asked to watch their child performing the pain task. Findings revealed, for both studies, that parents with a high level of catastrophic thinking about their child’s pain experienced more distress and a greater behavioral tendency of wanting to stop their child’s pain-inducing activity. Further, parental feelings of distress mediated the relationship between parental catastrophic thinking and parents’ tendency to restrict their child’s activity. The findings are discussed in light of an affective-motivational conceptualization of pain and pain behavior.     

Pain catastrophizing is related to temporal summation of pain but not temporal summation of the nociceptive flexion reflex

Pain catastrophizing is associated with enhanced temporal summation of pain (TS-Pain). However, because prior studies have found that pain catastrophizing is not associated with a measure of spinal nociception (nociceptive flexion reflex [NFR] threshold), this association may not result from changes in spinal nociceptive processes. The goal of the present study in healthy participants was to examine the relationship between trait (traditional) and state (situation-specific) pain catastrophizing and temporal summation of NFR (TS-NFR) and TS-Pain. A secondary goal was to replicate prior findings concerning relationships between catastrophizing and NFR threshold, electrocutaneous pain threshold, and sensory and affective ratings of electrocutaneous stimuli. All analyses controlled for depression symptoms, pain-related anxiety, and participant sex. As expected, multiple regression analyses indicated that neither trait nor situation-specific catastrophizing was associated with NFR threshold, but that situation-specific catastrophizing was associated with pain ratings. Multilevel linear growth models of TS data indicated that situation-specific catastrophizing was associated with TS-Pain but not TS-NFR. Trait catastrophizing was not related to TS-Pain or TS-NFR. Together, these results confirm prior studies that indicate that catastrophizing enhances pain via supraspinal processes rather than spinal processes. Moreover, because catastrophizing was associated with TS-Pain but not TS-NFR, caution is warranted when using pain ratings to infer temporal summation of spinal nociceptive processes.     

Why women prefer epidural analgesia during childbirth: the role of beliefs about epidural analgesia and pain catastrophizing.

This study investigated the reasons that might lead women to choose or not choose epidural analgesia as a strategy for the management of pain in childbirth. In our sample 55% of 114 women chose EA. Logistic regression resulted in a statistical model with four unique and independent predictors: Parity status and the fear of the side effects of EA each reduced the odds of choosing EA by half, whereas the desire to have a pain-free childbirth and positive experiences with EA of family and friends each doubled the odds of choosing EA. Pain catastrophizing was not related to EA use. The lack of an interrelationship between pain catastrophizing and EA use is probably due to an ambivalent attitude towards EA in pain catastrophizers. Pain catastrophizing was positively associated with the fear of being overwhelmed by labour pain and tendencies to avoid the pain, but also positively with the fear of pain during the insertion of the EA needle. Pain catastrophizing was also strongly related to recommendations to use EA from others, in particular from the midwife and from the gynecologist. Results are discussed in terms of the social impact of pain catastrophizing.     

Parental catastrophizing about children's pain and selective attention to varying levels of facial expression of pain in children: a dot-probe study

The attentional demand of pain has primarily been investigated within an intrapersonal context. Little is known about observers’ attentional processing of another’s pain. The present study investigated, within a sample of parents (n = 65; 51 mothers, 14 fathers) of school children, parental selective attention to children’s facial display of pain and the moderating role of child’s facial expressiveness of pain and parental catastrophizing about their child’s pain. Parents performed a dot-probe task in which child facial display of pain (of varying pain expressiveness) were presented. Findings provided evidence of parental selective attention to child pain displays. Low facial displays of pain appeared sufficiently and also, as compared with higher facial displays of pain, equally capable of engaging parents’ attention to the location of threat. Severity of facial displays of pain had a nonspatial effect on attention; that is, there was increased interference (ie, delayed responding) with increasing facial expressiveness. This interference effect was particularly pronounced for high-catastrophizing parents, suggesting that being confronted with increasing child pain displays becomes particularly demanding for high-catastrophizing parents. Finally, parents with higher levels of catastrophizing increasingly attended away from low pain expressions, whereas selective attention to high-pain expressions did not differ between high-catastrophizing and low-catastrophizing parents. Theoretical implications and further research directions are discussed.     

Development in quality of relationship between the significant other and the lung cancer patient as perceived by the significant other

AIM: To prospectively explore the quality of the relationship between significant others and patients during lung cancer, based on the perceptions of the significant others. METHOD: In a sample of 91 significant others, longitudinal data were collected during the first year after diagnosis, and explored on group level and as individual patterns over time. RESULTS: Relational quality was skewed towards high quality, although 30% of the significant others reported low levels close to diagnosis. Forty-eight percent reported stability in the quality of their relationship during the disease trajectory. Within this group, 36% reported low levels of relational quality. Fifty-two percent reported change in quality of relationship and four typical patterns of change were identified. Two showed approximate linear changes in either a positive direction (15%) or a negative direction (49%), and two showed non-linear changes with a temporary ascending curve (11%) or a descending curve (26%). This implies that a change towards low levels of relational quality was most common. CONCLUSION: The present results show that illness may be a trigger for change in relational quality, which may have implications for future family-centred practice and research, since previously high relational quality has been linked to improved emotional well-being.     

Evidence for a biopsychosocial influence on shoulder pain: pain catastrophizing and catechol-O-methyltransferase (COMT) diplotype predict clinical pain ratings

The experience of pain is believed to be influenced by social, cultural, environmental, psychological, and genetic factors. Despite this assertion, few studies have included clinically relevant pain phenotypes when investigating interactions among these variables. This study investigated whether psychological variables specific to fear-avoidance models and catechol-O-methyltransferase (COMT) genotype influenced pain ratings for a cohort of patients receiving operative treatment of shoulder pain. Patients (n = 58) completed questionnaires and had COMT genotype determined pre-operatively. Then, shoulder pain ratings were collected 3–5 months post-operatively. This cohort consisted of 24 females and 34 males, with mean age of 50.3 (SD = 15.0) and pre-operative pain rating of 4.5/10 (SD = 1.8). The frequency of COMT diplotypes was 34 with “high COMT activity” (LPS group) and 24 with “low COMT activity” (APS/HPS group). Preliminary analysis indicated that of all the fear-avoidance variables considered (fear of pain, kinesiophobia, pain catastrophizing, and anxiety), only pain catastrophizing was a unique contributor to clinical pain ratings. A hierarchical regression model indicated that an interaction between pain catastrophizing and COMT diplotype contributed additional variance in pre-operative pain ratings. The pain catastrophizing × COMT diplotype interaction demonstrated predictive validity as patients with high pain catastrophizing and low COMT activity (APS/HPS group) were more likely (RR = 6.8, 95% CI = 2.8–16.7) to have post-operative pain ratings of 4.0/10 or higher. Our findings suggest that an interaction between pain catastrophizing and COMT diplotype has the potential to influence pain ratings in patients seeking operative treatment of their shoulder pain.     

Impact of parental catastrophizing and contextual threat on parents' emotional and behavioral responses to their child's pain

Limited research has addressed processes underlying parents' empathic responses to their child's pain. The present study investigated the effects of parental catastrophizing, threatening information about the child's pain, and child pain expression upon parental emotional and behavioral responses to their child's pain. A total of 56 school children participated in a heat pain task consisting of 48 trials while being observed by 1 of their parents. Trials were preceded by a blue or yellow circle, signaling possible pain stimulation (i.e., pain signal) or no pain stimulation (i.e., safety signal). Parents received either neutral or threatening information regarding the heat stimulus. Parents' negative emotional responses when anticipating their child's pain were assessed using psychophysiological measures- i.e., fear-potentiated startle and corrugator EMG activity. Parental behavioral response to their child's pain (i.e., pain attending talk) was assessed during a 3-minute parent-child interaction that followed the pain task. The Child Facial Coding System (CFCS) was used to assess children's facial pain expression during the pain task. Results indicated that receiving threatening information was associated with a stronger parental corrugator EMG activity during pain signals in comparison with safety signals. The same pattern was found for parental fear-potentiated startle reflex, particularly when the child's facial pain expression was high. In addition, parents who reported high levels of catastrophizing thought about their child's pain engaged, in comparison with low-catastrophizing parents, in more pain-attending talk when they received threatening information. The findings are discussed in the context of affective-motivational theories of pain.     

Children's catastrophic thinking about their pain predicts pain and disability 6 months later

Catastrophic thinking about pain has been identified as an important determinant of adjustment to pain, in both adults and children. No study has investigated the prospective and unique role of catastrophizing in explaining later pain and disability in children. The aim of the present study was to investigate the prospective roles of catastrophic thinking about pain, pain intensity, and trait anxiety and their putative relationship with pain and disability tested 6 months later. Participants were 323 schoolchildren. Analyses revealed that the child's pain catastrophizing at baseline had a small but unique contribution to the prediction of pain and disability 6 months later, even when controlling for the initial pain and disability levels. In line with expectations, moderation analyses revealed that the effects of catastrophizing upon pain and disability at follow‐up were only true for those children reporting low levels intensity of pain at baseline. The variability in disability and pain complaint could not be explained by trait anxiety. Instead anxious disposition might be best conceived of as a precursor of catastrophizing in children; i.e. children with higher levels of trait anxiety at baseline were more inclined to report higher levels of catastrophizing at follow‐up. The findings are discussed in terms of potential mechanisms through which catastrophizing might exert its negative impact upon pain and disability outcomes in children.