Geert Crombez

Pain-related fear is more disabling than pain itself : evidence on the role of pain-related fear in chronic back pain disability

There is growing evidence for the idea that in back pain patients, pain-related fear (fear of pain/physical activity/(re)injury) may be more disabling than pain itself. A number of questionnaires have been developed to quantify pain-related fears, including the Fear-Avoidance Beliefs Questionnaire (FABQ), the Tampa Scale for Kinesiophobia (TSK), and the Pain Anxiety Symptoms Scale (PASS). A total of 104 patients, presenting to a rehabilitation center or a comprehensive pain clinic with chronic low back pain were studied in three independent studies aimed at (1) replicating that pain-related fear is more disabling than pain itself (2) investigating the association between pain-related fear and poor behavioral performance and (3) investigating whether pain-related fear measures are better predictors of disability and behavioral performance than measures of general negative affect or general negative pain beliefs (e.g. pain catastrophizing). All three studies showed similar results. Highest correlations were found among the pain-related fear measures and measures of self-reported disability and behavioral performance. Even when controlling for sociodemographics, multiple regression analyses revealed that the subscales of the FABQ and the TSK were superior in predicting self-reported disability and poor behavioral performance. The PASS appeared more strongly associated with pain catastrophizing and negative affect, and was less predictive of pain disability and behavioral performance. Implications for chronic back pain assessment, prevention and treatment are discussed.

The Fear-Avoidance Model of Musculoskeletal Pain: Current State of Scientific Evidence

Research studies focusing on the fear-avoidance model have expanded considerably since the review by Vlaeyen and Linton (Vlaeyen J. W. S. & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 85(3), 317--332). The fear-avoidance model is a cognitive-behavioral account that explains why a minority of acute low back pain sufferers develop a chronic pain problem. This paper reviews the current state of scientific evidence for the individual components of the model: pain severity, pain catastrophizing, attention to pain, escape/avoidance behavior, disability, disuse, and vulnerabilities. Furthermore, support for the contribution of pain-related fear in the inception of low back pain, the development of chronic low back pain from an acute episode, and the maintenance of enduring pain, will be highlighted. Finally, available evidence on recent clinical applications is provided, and unresolved issues that need further exploration are discussed.

Pain Demands Attention: A Cognitive-Affective Model of the Interruptive Function of Pain

Pain interrupts and demands attention. The authors review evidence for how and why this interruption of attention is achieved. The interruptive function of pain depends on the relationship between pain-related characteristics (e.g., the threat value of pain) and the characteristics of the environmental demands (e.g., emotional arousal). A model of the interruptive function of pain is developed that holds that pain is selected for action from within complex affective and motivational environments to urge escape. The implications of this model for research and therapy are outlined with an emphasis on the redefinition of chronic pain as chronic interruption.

A confirmatory factor analysis of the Pain Catastrophizing Scale: invariant factor structure across clinical and non-clinical populations

&NA; This study examined the factor structure of the Pain Catastrophizing Scale in three different Dutch‐speaking samples: 550 pain‐free students, 162 chronic low back pain patients, and 100 fibromyalgia patients. Confirmatory factor analyses were used to compare three different models of pain catastrophizing (one factor, two oblique factors, three oblique factors), and to investigate the invariance of the factor structure across the three different samples. The results indicated that a three‐factor oblique model with a four‐item rumination factor, a three‐item magnification factor, and a six‐item helplessness factor provided the best fit to the data in the three samples. Furthermore, it was found that this model could be considered as invariant across three samples (pain‐free students, chronic low back pain patients, and fibromyalgia patients) and across gender, indicating that the same processes are measured in different subgroups.

Facing others in pain: the effects of empathy.

Department of Experimental-Clinical and Health Psychology, Ghent University, Ghent, Belgium Research Institute for Psychology & Health, Utrecht, The Netherlands Department of Psychology, University of British Columbia, Vancouver, BC, Canada Academic Unit of Psychiatry & Behavioural Sciences, University of Leeds, Leeds, UK Department of Psychology, University of Montreal, Quebec, Canada Sub-Department of Clinical Health Psychology, University College London, London, UK Department of Psychology, Wayne State University, Detroit, MI, USA

Evaluative Conditioning in Humans: A Meta-Analysis

This article presents a meta-analysis of research on evaluative conditioning (EC), defined as a change in the liking of a stimulus (conditioned stimulus; CS) that results from pairing that stimulus with other positive or negative stimuli (unconditioned stimulus; US). Across a total of 214 studies included in the main sample, the mean EC effect was d = .52, with a 95% confidence interval of .466-.582. As estimated from a random-effects model, about 70% of the variance in effect sizes were attributable to true systematic variation rather than sampling error. Moderator analyses were conducted to partially explain this variation, both as a function of concrete aspects of the procedural implementation and as a function of the abstract aspects of the relation between CS and US. Among a range of other findings, EC effects were stronger for high than for low contingency awareness, for supraliminal than for subliminal US presentation, for postacquisition than for postextinction effects, and for self-report than for implicit measures. These findings are discussed with regard to the procedural boundary conditions of EC and theoretical accounts about the mental processes underlying EC.

Fear-avoidance model of chronic pain: the next generation.

Objective:The fear-avoidance (FA) model of chronic pain describes how individuals experiencing acute pain may become trapped into a vicious circle of chronic disability and suffering. We propose to extend the FA model by adopting a motivational perspective on chronic pain and disability. Methods:A narrative review. Results:There is ample evidence to support the validity of the FA model as originally formulated. There are, however, some key challenges that call for a next generation of the FA model. First, the FA model has its roots in psychopathology, and investigators will have to find a way to account for findings that do not easily fit within such framework. Second, the FA model needs to address the dynamics and complexities of disability and functional recovery. Third, the FA model should incorporate the idea that pain-related fear and avoidance occurs in a context of multiple and often competing personal goals. Discussion:To address these 3 key challenges, we argue that the next generation of the FA model needs to more explicitly adopt a motivational perspective, one that is built around the organizing powers of goals and self-regulatory processes. Using this framework, the FA model is recast as capturing the persistent but futile attempts to solve pain-related problems to protect and restore life goals.

When somatic information threatens, catastrophic thinking enhances attentional interference

&NA; Styles of catastrophic thinking about pain have been related to an inability to divert attention away from pain. We investigated whether pain catastrophizers displayed high attentional interference during a threatening low‐intensity electrocutaneous stimulus (ES). In Experiment 1, 44 undergraduates performed a tone discrimination task whilst experiencing several times an ES on the left or right arms. Tones were also presented 250 ms and 750 ms after ES onset. Participants were threatened that a high‐intensity painful stimulus would occur at one site. As predicted, pain catastrophizers displayed pronounced task interference immediately after threat stimulus onset. In Experiment 2, threat was induced in 36 undergraduates by informing them that an ES excites pain fibres. Again, catastrophizers had marked interference immediately after onset. The results are discussed in terms of how catastrophizing amplifies somatosensory information and primes fear mechanisms.

The child version of the pain catastrophizing scale (PCS-C): a preliminary validation.

Catastrophizing about pain has emerged as a critical variable in how we understand adjustment to pain in both adults and children. In children, however, current methods of measuring catastrophizing about pain rely on brief subscales of larger coping inventories. Therefore, we adapted the Pain Catastrophizing Scale (Sullivan et al., 1995) for use in children, and investigated its construct and predictive validity in two studies. Study 1 revealed that in a community sample (400 boys, 414 girls; age range between 8 years 9 months and 16 years 5 months) the Pain Catastrophizing Scale for Children (PCS‐C) assesses the independent but strongly related dimensions of rumination, magnification and helplessness that are subsumed under the higher‐order construct of pain catastrophizing. This three factor structure is invariant across age groups and gender. Study 2 revealed in a clinical sample of children with chronic or recurrent pain (23 girls, 20 boys; age range between 8 years 3 months and 16 years 6 months) that catastrophizing about pain had a unique contribution in predicting pain intensity beyond gender and age, and in predicting disability, beyond gender, age and pain intensity. The function of pain catastrophizing is discussed in terms of the facilitation of escape from pain, and of the communication of distress to significant others.

Adolescent chronic pain: patterns and predictors of emotional distress in adolescents with chronic pain and their parents

&NA; Adolescents with chronic pain also report severe disability and emotional distress. A clinical sample of 80 adolescents and accompanying parents were investigated to first measure the extent of distress, and second to investigate the relationships between adolescent distress, parental distress and adolescent coping. Measures of pain intensity, anxiety, depression, disability and coping were obtained from adolescents. Parents completed measures including their own anxiety, depression and parenting stress. Overall, adolescents reported high levels of disability, depression and anxiety, and parents reported high levels of depression, anxiety and parenting stress. Multiple regression analyses revealed that the best predictors of adolescent emotional distress were the extent to which the adolescents catastrophize and seek social support to cope with the pain. There were no clear predictors of parental anxiety or depression but the specific pattern of parenting stress was best predicted by the younger age of the adolescent, the greater the chronicity of the problem, and the greater the extent of adolescent depression. These findings suggest that emotional coping is a critical variable in the distress associated with adolescent chronic pain. It is argued that adolescent emotional coping may best be understood within a relational context of seeking emotional support.