Comparing the Effects of Thought Suppression and Focused Distraction on Pain-Related Attentional Biases in Men and Women.

Increasing attentional focus away from pain can affect pain experience, suggesting that cognitive strategies that move attentional allocation may be a moderator of pain. In a pre-post-design, the present study examined the effects of 2 cognitive strategies used in pain contexts, thought suppression and focused distraction, on subsequent pain-related attention. Thought suppression was hypothesized to increase pain-related attention, whereas focused distraction was expected to reduce it. Influences of both anxiety and sex were also considered, as secondary questions. 139 (86 women, 53 men) healthy, pain-free participants were randomly assigned to use either thought suppression or focused distraction during a mild cold pressor test (CPT). Pain-related attention was examined using a dot-probe and an attentional blink task, pre-and post-CPT. Questionnaires about relevant cognitive and emotional aspects, demographics, and pain were completed. Results showed no difference in the effect of the 2 pain inhibition strategies on pain-related attention. The hypothesized rebound effect in thought suppression on pain-related attention did not emerge. However, thought suppression showed a short-term benefit in comparison to focused distraction regarding reported pain and perceived threat during the cold pressor test. Few sex differences were found. Thus, the cognitive strategies affected pain outcomes, but did not influence pain-related attention. PERSPECTIVE: Cognitive strategies could help with pain through changing attention allocation. In this study, the effects of the 2 cognitive strategies thought suppression and focused distraction on pain-related attention in men and women were examined. Elucidating mechanisms that lie behind pain strategies that focus on changing attention may help improve treatments.

Endogenous Modulation of Pain: The Role of Exercise, Stress, and Cognitions in Humans.

BACKGROUND: Pain is a complex and highly subjective phenomenon that can be modulated by several factors. On the basis of results from experimental and clinical studies, the existence of endogenous pain modulatory mechanisms that can increase or diminish the experience of pain is now accepted. METHODS: In this narrative review, the pain modulatory effects of exercise, stress, and cognitions in humans are assessed. RESULTS: Experimental studies on the effect of exercise have revealed that pain-free participants show a hypoalgesic response after exercise. However, in some patients with chronic pain, this response is reduced or even hyperalgesic in nature. These findings will be discussed from a mechanistic point of view. Stress is another modulator of the pain experience. Although acute stress may induce hypoalgesia, ongoing clinical stress has detrimental effects on pain in many patients with chronic pain conditions, which have implications for the understanding, assessment, and treatment of stress in patients with pain. Finally, cognitive strategies play differing roles in pain inhibition. Two intuitive strategies, thought suppression and focused distraction, will be reviewed as regards experimental, acute, and chronic pain. CONCLUSION: On the basis of current knowledge on the role of exercise, stress, and cognitive pain control strategies on the modulation of pain, implications for treatment will be discussed.

Pain anxiety and fear of (re)injury in patients with chronic back pain: Sex as a moderator.

BACKGROUND AND AIMS: Anxiety and fear are increasingly seen as related, but distinct concepts, with anxiety describing a reaction to unclear or future threats, and fear to immediate threats. Anxiety and fear both play influential roles in pain. Yet, the two concepts have not been clearly distinguished in pain research. Their reported intensity differs between the sexes, and sex differences in the way pain anxiety and fear of (re)injury relate to pain intensity have been found separately in previous studies. However, they seem to be of a curious nature: In one study, pain anxiety was associated with elevated pain intensity in men, while in another, fear of (re)injury was associated with elevated pain intensity in women. This indicates a moderator effect of sex. The present study is the first to unite previous findings, and to show a more integrative picture, by examining and discussing this moderator effect of sex in a joint study of both pain-related anxiety and fear in both sexes. METHODS: In 133 patients (mean age 43.6 years, 62% female) with chronic low back pain (mean duration 7.7 years), sex differences were examined with correlations and a multiple linear regression analysis with interaction terms. Differences between subgroups of low and high anxiety/fear were explored via t-tests, following previous studies. RESULTS: Sex was supported as a moderator in the association of pain intensity with pain anxiety (PASS-20), and fear of (re)injury (TSK). Higher pain intensity was linked to higher pain anxiety only in men, and to higher fear of (re)injury only in women. A basic regression model with fear, anxiety, sex and disability as predictors (R2=.14, F(4,123)=3.24, p=.042) was significantly improved by the addition of the interaction terms Fear×Sex and Anxiety×Sex (R2=.18, F(2,121)=4.90, p=.001), which were both shown as significant predictors for pain intensity. Further t-tests revealed a significant difference in pain intensity between high and low anxiety in men (t(47)=-2.34, p=.023, d=-.43), but not in women. Likewise, a significant difference in pain intensity between high and low fear showed in women (t(80)=-2.28, p=.025, d=-.42), but not in men. CONCLUSIONS: The results support a moderator effect of sex and suggest differential mechanisms between the sexes in pain anxiety and fear in development and maintenance of back pain. The current study is the first to report and analyse this moderator effect. As potential underlying mechanisms, evolution and socialization are discussed, which may elucidate why fear might be more relevant for pain in women, and anxiety more relevant for pain in men. IMPLICATIONS: The results indicate the need for a more cautious conceptual separation of fear and anxiety in research. Future studies on fear and anxiety in pain should be aware of the distinction, in order to avoid reporting only half of the picture. The next step would be to solidify the results in different samples, and to examine whether a distinction between anxiety and fear in the sexes could have any benefit in pain treatment.

The German PASS-20 in patients with low back pain: new aspects of convergent, divergent, and criterion-related validity.

BACKGROUND: The PASS-20 (McCracken and Dhingra, Pain Res Manag 7:45-50, 2002) is a shortened version of the Pain Anxiety Symptoms Scale (PASS), a self-report measure of pain anxiety. The PASS-20 demonstrates good psychometric characteristics but has not yet been validated in a German population. PURPOSE: The aims of the present study were to (1) examine the factor structure and psychometric characteristics of the German PASS-20; (2) investigate its construct validity with respect to depression, fear-avoidance, and endurance; and (3) determine its criterion-related validity with a special emphasis on pain, disability, and quality of life. METHOD: A principal component analysis was performed on a sample (N = 195) of patients with acute, subacute, and chronic low back pain. Reliability was examined with Cronbach's α. Validity was assessed by correlating the PASS-20 to measures of depression, anxiety, disability, quality of life, and avoidance-endurance-related behavioral pain responses. RESULTS: The original four-factor structure proposed for the PASS-20 was replicated using the original subscale labels. The reliability of the total score and the subscales was satisfactory to excellent, and both convergent and divergent validity were moderate to high in the expected directions, showing positive correlations with anxiety, fear, depression, and fear-avoidance and negative correlations with endurance and quality of life. The PASS-20 showed unique predictive ability and advantages over the Tampa Scale of Kinesiophobia. CONCLUSIONS: The results for the German PASS-20 support the original factor structure and provide evidence of satisfactory psychometric characteristics and usefulness in patients with low back pain.

Anxiety of patients undergoing CT imaging-an underestimated problem?

RATIONALE AND OBJECTIVES: Prospective evaluation of anxiety in patients undergoing computed tomography (CT) imaging using a standardized state-trait anxiety inventory (STAI-S) and identification of possible risk factors. MATERIAL AND METHODS: During a 9-month interval, patients undergoing CT were questioned using STAI-S. Additionally, 10 questions concerning specific procedure-related features (claustrophobia, radiation, administration of contrast, and so forth) were added. Moreover, sex, age, admitting subspecialty, organ region, reason for imaging, and prior imaging studies were recorded. Statistical analysis was performed using the Student t test and linear regression analysis; significance level was set to 5%. RESULTS: Of 6122 patients, 825 patients undergoing CT (14%) were included (67% men; average age, 54 ± 17 years). Average STAI was 42 ± 10 with women (45 ± 11 vs. 41 ± 10; P < .001) and patients who received intravenous contrast (43 ± 10 vs. 42 ± 11; P = .021) showing significantly higher anxiety levels compared to those without contrast. Patients with investigations of their extremities (41 ± 11 vs. 43 ± 10; P = .020) and trauma patients (41 ± 11 vs. 43 ± 10; P = .006) revealed significantly lower STAI results. Patients who had never received a CT scan before showed significantly greater STAI-S values than those with repeat studies (42 ± 10 vs. 41 ± 11; P = .036). Females had greater fears concerning examination results (P < .001), radiation exposure (P = .032), administration of contrast (P = .014), and claustrophobia (P < .001). Patients with known malignancies had a significantly higher level of anxiety concerning their CT results (P = .002). CONCLUSIONS: Anxiety does not only occur before MRI but also occur before CT. Its sources are manifold and include communication of CT results, administration of contrast agents, radiation exposure, and claustrophobia. In this setting, women seemed to be more receptive than men.

Fear and anxiety in the transition from acute to chronic pain: there is evidence for endurance besides avoidance.

Substantial evidence reveals that the fear of pain and pain anxiety play a significant role in the development of chronic pain and disability, although underlying mechanisms remain widely unknown. Recent studies indicate that endurance pain responses are important besides avoidance. The purpose of this brief narrative review is to provide an overview of research that argues for the integration of the mechanisms of associative learning, motivation and emotion regulation in order to understand the questions of how and why individuals respond with pain responses, which lead to long-term suffering. By using the avoidance-endurance model of pain, we provide a concept that elucidates a range of responses to pain, fear and anxiety that mediate the transition from acute to chronic pain.

Fear of movement/(Re)injury in low back pain: confirmatory validation of a German version of the Tampa Scale for Kinesiophobia.

BACKGROUND: The Tampa Scale for Kinesiophobia (TSK), an instrument for measuring fear of movement/(re)injury, has been confirmed as an important predictor for the persistence of pain-related disability. The aims of this study were to evaluate the psychometric properties of a German version of the TSK (TSK-GV), examining aspects of content validity with special focus on fear-avoidance and endurance, and to confirm criterion-related validity in patients with low back pain (LBP). METHODS: A total of 191 patients with LBP were included in this study. Several models with different factor structures from published studies were compared in a confirmatory factor analysis. Internal consistencies of the TSK-GV and its subscales were examined, and correlations with related self-report measures were calculated. RESULTS: The internal consistency of the TSK-GV was α = 0.73. A two-factor model with 11 items was found to be the best fit for our data. The two factors were labelled Somatic Focus (SF) and Activity Avoidance (AA). The total score, SF and AA revealed moderate to high correlations with other fear-avoidance variables. CONCLUSIONS: The TSK-GV is a reliable and valid measure for assessing the fear of movement/(re)injury.

Psychological impact of genetic counseling for hereditary nonpolyposis colorectal cancer: the role of cancer history, gender, age, and psychological distress.

AIMS: We prospectively examined the impact of an initial interdisciplinary genetic counseling (human geneticist, oncologist, and psycho-oncologist) on feelings of anxiety with a special focus on subgroups related to personal cancer history, gender, age, and education. RESULTS: At baseline, cancer-affected men revealed a significantly higher level of anxiety than unaffected men (p<0.05), whereas history of cancer did not play a role in women. Furthermore, a significant interaction between time, gender, and age was identified for change of anxiety. While women in general and men above 50 years revealed a significant reduction in anxiety, younger men did not show any change over time. A logistic regression indicated that clinical Hospital Anxiety and Depression Scale-A cases can be predicted by general distress (Brief Symptom Inventory) as well as by hereditary nonpolyposis colorectal cancer-related cognitions of intrusion and avoidance (impact of event scale) with a correct classification of 86%. CONCLUSIONS: Although initial hereditary nonpolyposis colorectal cancer counseling leads to an overall reduction of anxiety, differential effects of cancer history, gender, and age focus on subgroups of cancer-affected men, who may display unexpectedly high anxiety scores at baseline. Especially younger men do not seem to reduce this high anxiety level. Baseline anxiety was mainly determined by maladaptive situation-specific cognitions. Therefore, consulters should be more aware of anxiety-related cognitions in cancer-affected younger men.