Turning Pain Into Cues for Goal-Directed Behavior: Implementation Intentions Reduce Escape-Avoidance Behavior on a Painful Task.

UNLABELLED: Pain automatically elicits escape-avoidance behavior to avert bodily harm. In patients with chronic pain, long-term escape-avoidance behavior may increase the risk of chronic disability. The aim of the presents study was to examine whether implementation intentions reduce escape-avoidance behavior during painful tasks in healthy individuals. Implementation intentions are "if-then" self-statements associating situational cues with goal-directed behaviors. Seventy healthy participants performed a painful finger pressing task, preceded by either implementation intention instructions with pain or a nonpain cue as a cue for goal-directed behavior, or control instructions. Escape-avoidance behavior was operationalized as task duration and response rate. Inhibitory control was measured using the Stop Signal Task. The pain implementation intentions resulted in the longest task duration (P = .02), and thus less escape-avoidance behavior. Low inhibitory control was associated with shorter task duration (P = .03), and thus more escape-avoidance behavior. The nonpain implementation intentions resulted in the highest response rate, but only when inhibitory control was low (P = .04). Implementation intentions referring to pain or nonpain reduce escape-avoidance behavior on a painful task. It is worthwhile to examine whether individuals in pain and with low inhibitory control benefit from interventions that incorporate implementation intentions. PERSPECTIVE: To our knowledge, this study is the first to show that forming implementation intentions reduces escape-avoidance behavior during pain and fosters nonpain goal pursuit. The use of implementation intentions is indicated to be an intervention that could be of use in patients with pain, particularly when inhibitory control is low.

Comparing Counterconditioning and Extinction as Methods to Reduce Fear of Movement-Related Pain.

UNLABELLED: Cognitive-behavioral treatments for chronic pain typically target pain-related fear; exposure in vivo is a common treatment focusing on disconfirming harm expectancy of feared movements. Exposure therapy is tailored on Pavlovian extinction; an alternative fear reduction technique that also alters stimulus valence is counterconditioning. We compared both procedures to reduce pain-related fear using a voluntary joystick movement paradigm. Participants were randomly allocated to the counterconditioning or extinction group. During fear acquisition, moving the joystick in 2 directions (conditioned stimulus [CS+]) was followed by a painful electrocutaneous stimulus (pain-unconditioned stimulus [US]), whereas moving the joystick in 2 other directions was not (CS-). During fear reduction, 1 CS+ was extinguished, but another CS+ was still followed by pain in the extinction group; in the counterconditioning group, 1 CS+ was extinguished and followed by a monetary reward-US, and another CS+ was followed by both USs (pain-US and reward-US). The results indicate that counterconditioning effectively reduces pain-related fear but that it does not produce deeper fear reduction than extinction. Adding a reward-US to a painful movement attenuated neither fear nor the intensity/unpleasantness of the pain. Both procedures changed stimulus valence. We contend that changing the affective valence of feared movements might improve fear reduction and may prevent relapse. PERSPECTIVE: This article reports no immediate differences between counterconditioning and extinction in reducing pain-related fear in the laboratory. Unexpectedly, both methods also altered stimulus valence. However, we cautiously suggest that methods explicitly focusing on altering the affective valence of feared movements may improve the long-term effectiveness of fear reduction and prevent relapse.

A content analysis of activity pacing in chronic pain: what are we measuring and why?

BACKGROUND: Activity pacing is a common intervention for patients with chronic pain. Over the past decade a number of instruments have been developed to measure this construct, but their comparative psychometric properties have not been examined. OBJECTIVE: To review the psychometric properties of existing measures of activity pacing, and provide suggestions for future research in this emerging area of pain research. METHODS: A narrative review of current measures of activity pacing followed by a discussion of the conceptual and psychometric challenges in this area. RESULTS: Although there is evidence supporting activity pacing as a unitary construct, important differences remain among the various measures in terms of their item content and assumptions. All existing activity pacing measures include items that assess activity regulation, but vary in their specific content. Most importantly, questionnaire items often reflect different purposes of pacing behaviors. DISCUSSION: Current measures of activity pacing are inadequate. New measures are needed that are based on specific theoretical models; these measures should also make the goal or intent of pacing behaviors explicit. Improvements in the assessment of activity pacing will likely lead to a better understanding of the pacing construct and the effects of pacing interventions.

Mood, stop-rules and task persistence: no mood-as-input effects in the context of pain.

BACKGROUND AND OBJECTIVES: Task persistence despite experiencing pain might be a risk factor for development and maintenance of chronic pain. The Mood-as-Input (MAI) model predicts that the impact of mood on individuals' motivation to persist in a task depends on the interpretation of current mood within a certain motivational context. The aim of the current study was to replicate the original MAI study (Martin, Ward, Achee, & Wyer, 1993), but in a context where the task is painful. METHODS: A 2 Mood (negative versus positive) × 2 Stop-Rule (achievement versus hedonic) between-subjects factorial design was used in which 120 healthy participants (97 women, mean age = 21.78 years, SD = 3.07) performed an impression-formation task while being exposed to mechanically induced pressure pain. RESULTS: The MAI interaction hypothesis was not confirmed. Instead, participants showed more task persistence when they used hedonic stop-rules as a ground to decide on task (dis)continuation than when they used an achievement-oriented stop-rule. Additionally, participants reporting less pain-related fear also spent more time on the painful impression-formation task. The current findings suggest that the MAI perspective might not apply to task persistence behavior in a pain context. LIMITATIONS: These findings may not generalize to task performance in patients with chronic pain.

Goals, mood and performance duration on cognitive tasks during experimentally induced mechanical pressure pain.

BACKGROUND: The present study tested the hypothesis that the affective and motivational context influences performance duration in the presence of pain. More specifically, the Mood-as-Input model (MAI) proposes that the interaction between goals and moods affects performance duration. When people adopt achievement goals, negative, as opposed to positive moods, signal that not enough progress has been made leading to task continuance. Negative as opposed to positive moods lead to task disengagement when adopting hedonic goals. METHODS: Participants completed three open-ended cognitive tasks while being exposed to mechanical pressure pain to a finger. Before each task, mood (positive versus negative) and goal pursuit (hedonic versus achievement) were manipulated, with mood as between-subjects and goal pursuit as within-subjects factor. Performance duration was the dependent variable and goal order and performance duration during a no-goal task were the covariates. RESULTS: In line with common theories on goals and mood, but in contrast to the MAI model, only main effects were found of mood and goal pursuit. Participants showed greater performance duration in an achievement than in a hedonic goal context. Moreover, they showed greater performance duration in relative positive than negative moods. LIMITATIONS: Pain may have decreased participants' mood below a certain threshold, which in turn may have obscured the MAI interaction effect. CONCLUSIONS: This study demonstrates that affective and motivational factors influence performance duration in a pain context.

Effects of responsibility and mood on painful task persistence.

BACKGROUND AND OBJECTIVES: Not just avoidance behaviour, but also painful task persistence might be a risk factor for development and maintenance of pain complaints. In seeking to understand these dysfunctional patterns of task performance, it has been suggested that mood influences the individuals' motivation to persist in a task depending on the interpretation of current mood within a certain motivational context. The aim of the present study was to test the effects of a social responsibility context and mood on persistence on a painful finger pressing task. METHODS: A 2 Mood (positive vs. negative) × 2 Responsibility (high vs. neutral) between-subjects factorial design was used in which 79 healthy participants (53 women; mean age = 22.99 years, SD = 4.77) performed the finger pressing task. RESULTS: The results show that mood and sense of responsibility independently influence task persistence: participants in a negative as opposed to positive mood spent more time on the task; the same was true for participants who reported a stronger sense of responsibility. In addition, an increase in pain during the task was associated with longer task persistence. No effect of pain-related fear on task persistence was found. CONCLUSION: This experimental study was the first to demonstrate an effect of sense of responsibility on persistence in a painful physical task.

Activity pacing in chronic pain: concepts, evidence, and future directions.

BACKGROUND: Activity pacing (AP) is a concept that is central to many chronic pain theories and treatments, yet there remains confusion regarding its definition and effects. OBJECTIVE: To review the current knowledge concerning AP and integrate this knowledge in a manner that allows for a clear definition and useful directions for future research. METHODS: A narrative review of the major theoretical approaches to AP and of the empirical evidence regarding the effects of AP interventions, followed by an integrative discussion. RESULTS: The concept of AP is derived from 2 main traditions: operant and energy conservation. Although there are common elements across these traditions, significant conceptual and practical differences exist, which has led to confusion. Little empirical evidence exists concerning the efficacy of AP as a treatment for chronic pain. DISCUSSION: Future research on AP should be based on a clear theoretical foundation, consider the context in which the AP behavior occurs and the type of pacing problem ("underactivity" vs. "overactivity"), and should examine the impact of AP treatment on multiple clinical outcomes. We provide a provisional definition of AP and specific recommendations that we believe will move the field forward.

Pain catastrophizing, threat, and the informational value of mood: task persistence during a painful finger pressing task.

Pain catastrophizing has shown to predict avoidance behavior in acute and chronic pain, but the literature is inconsistent. The present study tested the hypothesis that current mood and threat context moderate the relationship between pain catastrophizing and performance duration. Affective-motivational models postulate that negative and positive moods provide information about whether an activity is respectively threatening or safe. Moreover, it has been proposed that stable cognitive schemas about threat influence behavior particularly in threat-relevant contexts. The present study aimed to establish whether pain catastrophizing is related to less or greater performance duration, when participants experience respectively negative or positive moods, particularly in a high threatening pain context. A 2 mood × 2 threat context between-subjects factorial design was applied in 89 healthy participants with pain catastrophizing as covariate and performance duration during a painful finger pressing task as dependent variables. As predicted, higher pain catastrophizing was associated with less performance duration when participants experienced negative moods. The opposite was found when participants experienced positive moods. Moreover, these relationships were most pronounced in a high threatening pain context. This study suggests that the relationship between pain catastrophizing and performance duration during painful activities is moderated by situational factors such as current mood and threat context.

Goals matter: Both achievement and pain-avoidance goals are associated with pain severity and disability in patients with low back and upper extremity pain.

It has been proposed that goal pursuit plays a role in the development of chronic pain disorders. On the basis of (affective) motivational theories, it was hypothesized that both long-term achievement goals and short-term hedonic goals would be related to increased levels of pain and disability, particularly in patients with high negative affect. Participants with musculoskeletal pain complaints (N=299) completed a battery of questionnaires including a novel goal pursuit questionnaire (GPQ) measuring the extent to which participants preferred hedonic goals (mood-management or pain-avoidance goals) over achievement goals in various situations. Explorative factor analysis of the GPQ resulted in a reliable pain-avoidance (α=.88) and mood-management subscale (α=.76). A nonlinear, U-shaped relationship was found among the pain-avoidance scale (but not the mood-management scale) and pain and disability. This indicated that participants who strongly endorsed either achievement or pain-avoidance goals also reported higher pain and disability levels while controlling for biographical variables and pain catastrophizing. For pain but not disability, these relationships were only found among patients with high negative affect. For disability, goal pursuit and negative affect were independently related to disability. These findings provide support for the validity of an affective-motivational approach to chronic pain, suggesting that the experience of pain and the interference of pain on daily life activities depends on goal pursuit and negative affect. Interventions aimed at improving disability in chronic pain should address both patient's goal pursuit and negative affect. An affective-motivational approach to chronic pain indicates that achievement and pain-avoidance goals are associated with pain severity and disability, particularly in patients with high negative affect.

The role of current mood and stop rules on physical task performance: an experimental investigation in patients with work-related upper extremity pain.

Patients with work-related upper extremity pain (WRUED) experience disability in daily life activities. The factors that influence levels of disability are still unclear. Both excessive avoidance and persistence have been suggested, but the affective and motivational processes that underlie these behaviours have not been scrutinized. This study was aimed at examining the role of current mood and stop rules on physical task performance, controlling for gender, pain severity, pain catastrophizing, and pain-related fear. An additional focus was the role of the interaction between current mood and stop rules as predicted by the novel Mood-as-Input (MAI) model. Following MAI, it is the informational value of current mood within a goal context (stop rule), rather than mood per se that predicts behaviour. A 2 (mood)x2 (stop rule)x2 (physical task order) factorial design was used in which 62 WRUED patients performed an upper and lower extremity physical task. A stress interview was used to induce positive and negative mood. Patients received either an "as-much-as-can (AMAC)" stop rule instruction, or a "feel-like-discontinuing (FLDC)" stop rule instruction. Results showed that physical task performance was predicted by pain-related fear, current mood, stop rule. However, the predicted moodxstop rule interaction was not found, and there was no influence of gender, pain severity, and pain catastrophizing on task performance. The findings suggest that not only pain-related fear, but current mood and goal context factors independently affect physical performance in patients with WRUED.

Active avoidance but not activity pacing is associated with disability in fibromyalgia.

Activity pacing has been suggested as a behavioural strategy that may protect patients with fibromyalgia (FM) against activity dysregulation and disability. The aim of the present study was to empirically test whether the construct of activity pacing is distinct from other behavioural strategies assessed with the Chronic Pain Coping Inventory (CPCI), such as guarding, resting, asking for assistance, relaxation, task persistence, exercise/stretch, seeking social support, and coping self-statements. The second objective was to test whether pacing was associated with physical disability when controlling for pain catastrophizing, pain severity and the other behavioural strategies as measured with CPCI. A random sample of patients with FM (N=409) completed the CPCI, the Pain Catastrophizing Scale (PCS), the Physical Index of the Fibromyalgia Impact Questionnaire (FIQ-PH) and the Pain Disability Index (PDI). The results demonstrated that the Dutch version of the CPCI including the pacing subscale has adequate internal consistency and construct validity. Moreover, guarding and asking for assistance, but not pacing, were associated with disability. These findings are in line with fear-avoidance models and suggest that specifically active avoidance behaviours are detrimental in FM. The authors recommend developing cognitive-behavioural and exposure-based interventions and challenge the idea that pacing as an intervention is essential in pain self-management programs.

False heart rate feedback and the perception of heart symptoms in patients with congenital heart disease and anxiety.

BACKGROUND: Little is known about the mechanisms explaining an increased perception of heart symptoms in congenital heart disease (ConHD). In the present study, it was suggested that a combination of high trait anxiety and disease history increases the perception of heart symptoms. PURPOSE: It was tested whether false heart cues will result in an increased perception of heart symptoms in patients with ConHD and anxiety. METHOD: Thirty-six patients with ConHD and 44 healthy controls performed two exercise tasks. During one of the exercise tasks, participants were exposed to a false heart cue consisting of false heart rate feedback (regular or irregular). Perceived heart symptoms were assessed and heart rate, arterial partial pressure of CO(2), and respirator rate were monitored continuously. RESULTS: In line with the predictions, false heart rate feedback resulted in an increased perception of heart symptoms in high trait anxious patients with ConHD that could not be explained by acute heart dysfunction. However, unexpectedly, this effect was not observed immediately after the false heart rate feedback task but after a second exercise task without false feedback. CONCLUSION: The results suggest that not the sole presence of ConHD but ConHD in combination with high trait anxiety results in a vulnerability to overperceive heart symptoms.

Interpretation bias for heart sensations in congenital heart disease and its relation to quality of life.

BACKGROUND: Previous studies have shown that patients with congenital heart disease (ConHD) report a diminished health-related quality of life. PURPOSE: This study examines the mechanisms by which ConHD affects health-related quality of life. We hypothesize that (1) the relation between trait anxiety and quality of life is mediated by a negative interpretation bias for heart sensations, specifically in ConHD, and that (2) the relation between trait anxiety and interpretation bias is mediated by state anxiety. METHOD: Sixty-six patients with ConHD and 50 healthy participants read a vignette about a person experiencing ambiguous heart-related sensations. Interpretation bias to these sensations was assessed with the Implicit Models of Illness Questionnaire. Participants completed Spielberger trait and state anxiety questionnaires and the physical subscales of a quality-of-life questionnaire. RESULTS: Path-analysis demonstrated that interpretation bias mediated the relation between trait anxiety and daily functioning. However, trait anxiety and interpretation bias were less influential with respect to gross motor functioning. Moreover, state anxiety mediated the relation between trait anxiety and interpretation bias. CONCLUSION: These results suggest that patients with ConHD who display both elevated levels of trait and state anxiety exhibit the most pronounced negative interpretation bias for heart sensations and in turn diminished daily functioning.

Preattentive processing of heart cues and the perception of heart symptoms in congenital heart disease.

The present study was aimed at clarifying whether preattentive processing of heart cues results in biased perception of heart sensations in patients with congenital heart disease (ConHD) who are also highly trait anxious. Twenty-six patients with ConHD and 22 healthy participants categorized heart-related (heart rate) or neutral sensations (constant vibration) as either heart or neutral. Both sensations were evoked using a bass speaker that was attached on the chest of the participant. Before each physical sensation, a subliminal heart-related or neutral prime was presented. Biased perception of heart-sensations would become evident by a delayed categorization of the heart-related sensations. In line with the prediction, a combination of high trait anxiety and ConHD resulted in slower responses after a heart-related sensation that was preceded by a subliminal heart cue. Preattentive processing of harmless heart cues may easily elicit overperception of heart symptoms in highly trait anxious patients with ConHD.

Stress-induced heart symptoms and perceptual biases in patients with congenital heart disease.

BACKGROUND: The aim of the present study is to clarify whether biased symptom perception towards heart symptoms may explain a reduced quality of life in patients with congenital heart disease (ConHD). The present study tested the hypothesis that the combination of ConHD and high trait anxiety increases the perception of heart symptoms during acute stress. METHODS: 25 patients and 24 healthy participants completed a stressful computer task. Participant's heart and non-heart symptoms were measured after stress and after relaxation. Heart rate, blood pressure, respiratory rate, and arterial partial pressure of CO2 were monitored continuously. RESULTS: In line with the prediction, a combination of high trait anxiety and ConHD resulted in an increased perception of specifically heart symptoms during stress. Moreover, the increased perception of heart symptoms could not be explained by acute heart dysfunction. CONCLUSIONS: Heart dysfunction is not the only cause of an increased perception of heart symptoms. A history of disease experience in combination with high trait anxiety may increase the perception of heart symptoms during stress and may eventually result in an increased risk of developing a reduced quality of life.

Psychological and cognitive functioning in children and adolescents with congenital heart disease: a meta-analysis.

OBJECTIVE: Findings in the literature are inconsistent on the impact of congenital heart disease (CHD) on the psychological and cognitive functioning of children and adolescents. The aim of the present study was to systematically review this empirical body of literature. METHODS: We conducted a meta-analysis to review studies on behavior problems and cognitive functioning in CHD. RESULTS: Only older children and adolescents with CHD displayed an increased risk of overall, internalizing, and to a lesser extent externalizing behavior problems. In addition, patients with severe CHD exhibited lower cognitive functioning than patients with less severe CHD, specifically with respect to performance intelligence. Moreover, decreased cognitive functioning remained relatively stable across different age groups. CONCLUSIONS: Children with severe heart disease may benefit from interventions specifically targeting perceptual organizational abilities, such as visual-spatial abilities. Moreover, older children and adolescents with CHD may benefit from psychological interventions reducing anxiety symptoms and depression.

Heartbeat sensitivity in adults with congenital heart disease.

This study tested the hypothesis that patients with a congenital heart disease are sensitive regarding heartbeat perception, reflected in enhanced attention for heartbeat, estimation of own heart rate, and a vulnerability to become anxious by listening to heartbeat sounds. Twenty adults with a congenital heart disease, and 20 healthy controls conducted 3 experimental tasks: a concentration task during distraction by heartbeat sounds, own heart rate estimation, and exposure to different patterns of heartbeat sounds. The results showed that patients were more distracted by heartbeat, and were also worse at estimating heart rate than controls. However, heartbeat sounds did not evoke anxiety. In conclusion, patients with a congenital heart disease may differ from controls in heartbeat perception, but there was no support for obsessive monitoring for heartbeat or excessive reactions to heartbeat sounds.

Group cohesion and working alliance: prediction of treatment outcome in cardiac patients receiving cognitive behavioral group psychotherapy.

BACKGROUND: Various definitions of both group cohesion and working alliance are used in theories on group psychotherapy, making the study of their relative contribution to the treatment outcome difficult. In this study, two different, nonoverlapping questionnaires were used to explore the relationship between group cohesion, working alliance and treatment outcome in a time-limited, structured cognitive behavioral group psychotherapy aiming at the reduction of coronary risk factors. METHODS: After having undergone percutaneous transluminal coronary angioplasty, 42 patients were treated with the aim to reduce exhaustion, anxiety, hostility and depression. The newly developed Group Cohesion Questionnaire (GCQ) and the Helping Alliance Questionnaire (HAQ-II, measuring the bond between individual patients and the group psychotherapist) were administered after the fifth and tenth treatment session. Exhaustion, quality of life, anxiety, blood pressure and heart rate were measured before and after treatment. To test the relationship between the GCQ, the HAQ-II and outcome variables, Pearson Product-Moment correlations and hierarchical regression was applied. RESULTS: Principal Component Analysis of the GCQ yielded two dimensions, the bond with the group as a whole and the bond with other group members. Hierarchical regression showed that both the bond with other group members and working alliance contributed significantly and independently to the prediction of posttreatment systolic and diastolic blood pressure as well as posttreatment quality of life (confidence). CONCLUSIONS: Conceptually and empirically, group cohesion and the working alliance may be considered to represent different relationships in a psychotherapy group, contributing in different ways to the treatment outcome in cardiac patients receiving cognitive behavioral group psychotherapy.