Lauren C. Heathcote

Systematic Review and Meta-Analysis of Psychological Therapies for Children With Chronic Pain

OBJECTIVES This systematic review and meta-analysis examined the effects of psychological therapies for management of chronic pain in children.  METHODS Randomized controlled trials of psychological interventions treating children (<18 years) with chronic pain conditions including headache, abdominal, musculoskeletal, or neuropathic pain were searched for. Pain symptoms, disability, depression, anxiety, and sleep outcomes were extracted. Risk of bias was assessed and quality of the evidence was rated using GRADE.  RESULTS 35 included studies revealed that across all chronic pain conditions, psychological interventions reduced pain symptoms and disability posttreatment. Individual pain conditions were analyzed separately. Sleep outcomes were not reported in any trials. Optimal dose of treatment was explored. For headache pain, higher treatment dose led to greater reductions in pain. No effect of dosage was found for other chronic pain conditions.  CONCLUSIONS Evidence for psychological therapies treating chronic pain is promising. Recommendations for clinical practice and research are presented.

The relationship between adolescents' pain catastrophizing and attention bias to pain faces is moderated by attention control

Abstract This study considered the attentional functioning of adolescents with varying levels of pain catastrophizing. Specifically, we investigated the relationship between pain catastrophizing and attention bias to pain facial expressions. Furthermore, drawing on dual process models in the context of pain, we investigated the moderating role of attention control on this relationship. Adolescents (N = 73; age, 16-18 years) performed a dot-probe task in which facial expressions of pain and neutral expressions were presented for 100 milliseconds and 1250 milliseconds. Participants also completed self-report pain catastrophizing and attention control measures. We found that although there was no main effect of pain catastrophizing on attention bias towards pain faces, attention control did significantly moderate this relationship. Further analysis revealed that lower levels of attention control were significantly associated with increasing attentional vigilance towards pain faces only within high catastrophizing adolescents. In addition, we found that poorer attention control was related to increased attention bias for pain faces (regardless of pain catastrophizing level) when these faces were presented for relatively longer durations (ie, 1250 milliseconds) but not for short durations (ie, 100 milliseconds). This study supports a dual process model of attentional processes in pain, thus replicating previous findings within the psychopathology literature but extending them to the study of pain. Theoretical and clinical implications of our findings are discussed.

Age-related changes in attentional control across adolescence: how does this impact emotion regulation capacities?

This study set out to establish the novel use of the go/no-go Overlap task for investigating the role of attentional control capacities in the processing of emotional expressions across different age-groups within adolescence: at the onset of adolescence (11–12 year-olds) and toward the end of adolescence (17–18 year-olds). We also looked at how attentional control in the processing of fearful, happy, and neutral expressions relates to individual differences in trait anxiety in these adolescent groups. We were able to show that younger adolescents, but not older adolescents had more difficulties with attention control in the presence of all faces, but particularly in the presence of fearful faces. Moreover, we found that across all groups, adolescents with higher trait anxiety exhibited attentional avoidance of all faces, which facilitated relatively better performance on the primary task. These differences in reaction time emerged in the context of comparable accuracy level in the primary task across age-groups. Our results contribute to our understanding of how attentional control abilities to faces but in particular fearful expressions may mature across adolescence. This may affect learning about the environment and the acquisition of behavioral response patterns in the social world.

Child attention to pain and pain tolerance are dependent upon anxiety and attention control: An eye-tracking study.

Pain is common and can be debilitating in childhood. Theoretical models propose that attention to pain plays a key role in pain outcomes, however, very little research has investigated this in youth. This study examined how anxiety‐related variables and attention control interacted to predict childrens attention to pain cues using eye‐tracking methodology, and their pain tolerance on the cold pressor test (CPT).

The puzzle of attentional bias to pain: beyond attention.

Attentional bias (AB), the tendency for patients to pay attention selectively to information that is related to their current concerns, is a well-validated phenomenon in many forms of psychopathology. Information processing models assume that AB plays a role not only in the maintenance of psychopathology but also in the causal development of anxiety and depression. Sometimes referred to as hypervigilance, the investigation of AB has gained momentum in pain research. Meta-analyses have shown that patients with chronic pain indeed display an AB towards pain-related information, but the field is marked by large variability in findings, and sometimes by patterns of results that do not accord well with hypotheses. Some studies have added to the confusion by revealing that, instead of directing attention towards pain, there is sometimes a tendency to attend away from pain-related information. Todd et al. have taken up the challenge of bringing some cohesion to this puzzling but intriguing phenomenon, and we applaud their attempt to summarize and integrate the field. Their systematic review goes beyond available reviews by explicitly focusing on prospective studies that examine the value of AB in predicting pain-relevant outcomes such as pain, distress, and disability. Their review integrates findings that may appear inconsistent at first glance, and they have formulated a model that may prove a useful guide for future research. Although we agree that the proposed Threat Interpretation Model is useful, it is clear that more research is needed to validate the specific claims made by this model. It is also clear that our current arsenal of methods is not yet sufficient, and, in agreement with Todd et al., we suggest that researchers should now focus on the development of more reliable and pertinent experimental methods. First, research should include more direct and continuous measures of attention so as to better capture its dynamic nature. For example, eye-tracking methods can track eye movements to visual displays of stimuli, thereby providing more than the brief snapshot of attention that traditional AB paradigms are able to capture. Second, we think research should also focus on attention within the somatosensory modality. As yet, most of the literature on AB investigates attending towards visual representations of pain (pain words or pictures depicting facial expressions of pain), which may fundamentally differ from attentional processes towards pain itself or other bodily sensations. In addition, to make use of eye-tracking methods, visual stimuli could be contextualized within the context of somatosensory pain, eg, by associating these stimuli with pain through conditioning processes or by presenting pain words or facial expressions that provide information about an upcoming painful experience that the participant will undergo. A research agenda that exclusively focuses on AB may be insufficient, and the inclusion of interpretationwithin the proposed Threat Interpretation Model is a major strength. The idea that interpretational processes are the key drivers of AB is already included in many models of pain and AB and has been variously discussed in terms of the threat value of pain and the appraisal of pain as threatening or catastrophic. Despite some consensus, however, there is almost no research on the precise nature of these interpretational processes and their role on AB in pain. We have not yet passed the stage of using self-report questionnaires to assess how patients interpret their pain and to identify how both patients and those at risk for developing pain interpret cues for pain within an ambiguous environment. There are several paradigms available within the psychopathology literature, and some of them have been already applied to pain. Moreover, we can learn from models of psychopathology that also posit interpretational processes as key factors in the interplay between cognition and emotion. Interestingly, within these models, interpretational processes may also occur following attentional selection of emotionally relevant stimuli. This contrasts with the Threat Interpretation Model in which interpretation precedes attention. The interplay between interpretation and attention in terms of feedforward and feedbackmechanisms is an unexplored area of research. The call for research beyond attention, and to focus on interpretation, is not trivial. There is a growing interest in AB as a target for interventions that teach patients to direct their attention away from pain-related information. Initial positive results with AB modification for psychopathology have been reported but seem not to be substantiated in recent reviews. Attentional bias modification research in general is still in its infancy and is only beginning to be used within pain research. More detailed investigation, particularly by means of controlled trials, is undoubtedly needed. Nonetheless, if results for AB modification studies of pain echo those in psychopathology, wherein results are very mixed, progress may be slow. A more efficient way forward may be to target the meaning, the interpretation, or the threat value of pain. Clinical psychologists have a plethora of intervention techniques to accomplish this objective, and the field of experimental psychopathology can also provide novel tools to modify biased interpretations. Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. a Department of Experimental Clinical and Health Psychology, Ghent University, Ghent, Belgium, b Centre for Pain Research, University of Bath, Bath, United Kingdom, c Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom

Pain and cancer survival: a cognitive-affective model of symptom appraisal and the uncertain threat of disease recurrence

Forty years ago, three quarters of adults and children diagnosed with cancer died. Today, almost half of adults and three quarters of children survive. Survival, however, is rarely psychologically simple. Life after cancer can be characterised by an altered relationship with bodily perception: in particular an anxious uncertainty about the meaning of new or recurrent sensations such as pain. Cancer survival is an altered context in which pain can make one fear the worst. To date, research on the experience of pain in cancer survival has existed largely within a biological frame. That is, pain is studied as the result of tissue damage from the cancer itself or from surgery, chemotherapy, or radiotherapy. Yet, if there is one inescapable fact of pain science it is that tissue damagecannot alone explain pain andpainrelated behaviour. In this review, we discuss the threat associated with pain in cancer survival specifically how one manages the inherent uncertainty of pain as a potential symptom of cancer recurrence.We recognise that theword “survivor” is contentious; and here,we principally use “survival” to identify the post-treatment disease-free stage that individuals experience. We introduce a cognitive-affective model of pain appraisal and experience applied to a survival context, stressing both the clinical and research opportunities it provides.

Pain Neuroscience Education: State of the Art and Application in Pediatrics

Chronic pain is a widespread problem in the field of pediatrics. Many interventions to ameliorate pain-related dysfunction have a biobehavioral focus. As treatments for chronic pain (e.g., increased movement) often stand in stark contrast to treatments for an acute injury (e.g., rest), providing a solid rationale for treatment is necessary to gain patient and parent buy-in. Most pain treatment interventions incorporate psychoeducation, or pain neuroscience education (PNE), as an essential component, and in some cases, as a stand-alone approach. The current topical review focuses on the state of pain neuroscience education and its application to pediatric chronic pain. As very little research has examined pain neuroscience education in pediatrics, we aim to describe this emerging area and catalyze further work on this important topic. As the present literature has generally focused on adults with chronic pain, pain neuroscience education merits further attention in the realm of pediatric pain in order to be tailored and implemented in this population.

Biased interpretations of ambiguous bodily threat information in adolescents with chronic pain

Abstract Adult patients with chronic pain are consistently shown to interpret ambiguous health and bodily information in a pain-related and threatening way. This interpretation bias may play a role in the development and maintenance of pain and disability. However, no studies have yet investigated the role of interpretation bias in adolescent patients with pain, despite that pain often first becomes chronic in youth. We administered the Adolescent Interpretations of Bodily Threat (AIBT) task to adolescents with chronic pain (N = 66) and adolescents without chronic pain (N = 74). Adolescents were 10 to 18 years old and completed the study procedures either at the clinic (patient group) or at school (control group). We found that adolescents with chronic pain were less likely to endorse benign interpretations of ambiguous pain and bodily threat information than adolescents without chronic pain, particularly when reporting on the strength of belief in those interpretations being true. These differences between patients and controls were not evident for ambiguous social situations, and they could not be explained by differences in anxious or depressive symptoms. Furthermore, this interpretation pattern was associated with increased levels of disability among adolescent patients, even after controlling for severity of chronic pain and pain catastrophizing. The current findings extend our understanding of the role and nature of cognition in adolescent pain, and provide justification for using the AIBT task in longitudinal and training studies to further investigate causal associations between interpretation bias and chronic pain.

High trait anxiety during adolescence interferes with discriminatory context learning.

Persistent adult anxiety disorders often begin in adolescence. As emphasis on early treatment grows, we need a better understanding of how adolescent anxiety develops. In the current study, we used a fear conditioning paradigm to identify disruptions in cue and context threat-learning in 19 high anxious (HA) and 24 low anxious (LA) adolescents (12-17years). We presented three neutral female faces (conditioned stimulus, CS) in three contingent relations with an unconditioned stimulus (UCS, a shrieking female scream) in three virtual room contexts. The degree of contingency between the CSs and the UCSs varied across the rooms: in the predictable scream condition, the scream followed the face on 100% of trials; in the unpredictable scream condition, the scream and face appeared randomly and independently of each other; in the no-scream condition the CS was presented in the absence of any UCS. We found that the LA adolescents showed higher levels of fear-potentiated startle to the faces relative to the rooms. This difference was independent of the contingency condition. The HA adolescents showed non-differential startle between the CSs, but, in contrast to previous adult data, across both cue types displayed lowest startle to the unpredictable condition and highest startle to the no-scream condition. Our study is the first to examine context conditioning in adolescents, and our results suggest that high trait anxiety early in development may be associated with an inability to disambiguate the signalling roles of cues and contexts, and a mislabelling of safety or ambiguous signals.

Attention bias modification training for adolescents with chronic pain: A randomized placebo-controlled trial

Abstract Attention bias for pain-related information is theorised to maintain chronic pain, indicating that changing this bias could improve pain-related outcomes. Modifying attention biases in adolescents, when chronic pain often first emerges, may be particularly beneficial. We report here a randomized, placebo-controlled, parallel-group trial of attention bias modification (ABM) training in adolescents with chronic noncancer pain. Adolescent patients (N = 66) were randomly assigned to complete multiple sessions of dot-probe ABM training (N = 23), placebo training (N = 22), or no training (waitlist; N = 21) across a period of 4 weeks. Patients completed all assessments at a hospital-based pediatric pain clinic and completed all training at home. We examined the relative effects of ABM on attention bias and attention control, as well as pain symptomatology (primary outcome), pain catastrophizing, anxiety and depression symptoms, and functional disability (secondary outcomes) immediately after training and 3 months later. We found no evidence that ABM changed attention bias or attention control in comparison with placebo training or no training. We also found that pain and pain-related outcomes were no different for those undergoing ABM compared with placebo training or no training when tested immediately after training or 3 months later. Overall, we found no evidence to support the efficacy of dot-probe ABM for improving pain-related outcomes in adolescents with chronic pain. This study was registered on the NIHR Clinical Research Network Portfolio in August 2014 (UK Clinical Trials Gateway: CPMS 17251) and funded by a Research Training Fellowship awarded to Lauren Heathcote by Action Medical Research for Children.