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Self-compassion is the ability to respond to one's failures, shortcomings, and difficulties with kindness and openness rather than criticism. This study, which might be regarded as a proof-of-concept study, aimed to establish whether self-compassion is associated with expected emotional responses and the likelihood of responding with problem solving, support seeking, distraction, avoidance, rumination, or catastrophizing to unpleasant self-relevant events occurring in 3 social contexts. Sixty chronic pain patients were presented with 6 vignettes describing scenes in which the principal actor transgressed a social contract with negative interpersonal consequences. Vignettes represented 2 dimensions: (1) whether pain or a nonpain factor interrupted the fulfillment of the contract and (2) variation in the social setting (work, peer, and family). The Self-Compassion Scale was the covariate in the analysis. Higher levels of self-compassion were associated with significantly lower negative affect and lower reported likelihood of avoidance, catastrophizing, and rumination. Self-compassion did not interact with pain vs nonpain factor. Work-related vignettes were rated as more emotional and more likely to be associated with avoidance, catastrophizing, and rumination and less likelihood of problem solving. The findings suggest that self-compassion warrants further investigation in the chronic pain population both regarding the extent of its influence as a trait and in terms of the potential to enhance chronic pain patients' ability to be self-compassionate, with a view to its therapeutic utility in enhancing psychological well-being and adjustment. Limitations regarding the possible criterion contamination and the generalizability of vignette studies are discussed.

Enriched enrolment, randomised withdrawal (EERW) pain trials select, before randomisation, patients who respond by demonstrating a predetermined degree of pain relief and acceptance of adverse events. There is uncertainty over the value of this design. We report a systematic review of EERW trials in chronic noncancer pain together with a critical appraisal of methods and potential biases in the methods used and recommendations for the design and reporting of future EERW trials. Electronic and other searches found 25 EERW trials published between 1995 and June 2014, involving 5669 patients in a randomised withdrawal phase comparing drug with placebo; 13 (median, 107 patients) had a randomised withdrawal phase of 6 weeks or less, and 12 (median, 334) lasted 12 to 26 weeks. Risks of bias included short duration, inadequate outcome definition, incomplete outcome data reporting, small size, and inadequate dose tapering on randomisation to placebo. Active treatment was usually better than placebo (22/25 trials). This review reduces the uncertainty around the value of EERW trials in pain. If properly designed, conducted, and reported, they are feasible and useful for making decisions about pain therapies. Shorter, small studies can be explanatory; longer, larger studies can inform practice. Current evidence is inadequate for valid comparisons in outcome between EERW and classical trials, although no gross differences were found. This systematic review provides a framework for assessing potential biases and the value of the EERW trials, and for the design of future studies by making recommendations for the conduct and reporting of EERW trials.

This article reports the development of natural history and active treatment benchmarks for psychological treatments of chronic pain. The benchmarks were derived from randomized controlled trials (RCTs) reported in a published meta-analysis. In two preliminary studies we surveyed small samples of active clinicians working in U.K. pain management programs. Study 1 assessed the fit between routine clinical treatment and the selected RCTs. In study 2 Delphi methodology was used to determine a set of outcome domains to be used in the development of benchmarks. In study 3 we extracted data from a set of RCTs where both pre- and post-treatment data were reported. Measures were allocated to 1 of 5 outcome domains (cognitive coping and appraisal, pain experience, pain behavior, emotional functioning, and physical functioning). Pre-treatment to post-treatment effect sizes (Cohen's d) were computed and, where necessary, aggregated within trial so that each trial contributed a single estimate to outcome domain. Effect size (ES) benchmarks were computed for all trials and those trials with an explicit cognitive behavior therapy protocol. In no case did the ES estimates for the untreated control deviate from 0. The average ES across outcome domains for the treatment arms was approximately 0.35. These benchmarks may be used to assess the effectiveness of routine clinical treatments for chronic pain. The application of these data and the limitations of the study are discussed., (Copyright © 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Depression is a common feature of chronic pain, but there is limited research into the content and frequency of depressed cognitions in pain patients. A limitation of previous research is the failure to include nonpain depressed comparison groups. The present study used a sentence completion task to investigate the content of cognition in 4 groups of participants: with pain and concurrent depression, pain without depression, depression without pain, and with neither pain nor depression. One hundred seventy-two participants generated sentences to a set of predefined stems. Complete responses were coded by affective valence (negative, positive, and neutral) and health-related content. As predicted, participants with depression (with and without pain) produced more negative responses than nondepressed participants (with and without pain); participants with pain (depressed and nondepressed) produced more health responses than those without pain (depressed and controls); participants with depression and pain produced more negative health responses than any other group. The strengths of the current study are the inclusion of the depressed nonpain group, the use of a comprehensive coding scheme applied by 2 independent raters, and the presence of depression validated through a diagnostic interview. In contrast to depressed groups without pain, participants with pain and depression exhibit a cognitive bias specific to negative aspect of health. This focus facilitates understanding of the relationship between depression and pain processing: The implications for therapeutic interventions are discussed., (Copyright © 2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Research on the effectiveness of distraction as a method of pain control is inconclusive. One mechanism pertains to the motivational relevance of distraction tasks. In this study the motivation to engage in a distraction task during pain was experimentally manipulated. Undergraduate students (N=73) participated in a cold pressor test (CPT) and were randomly assigned to three groups: a distraction-only group performed a tone-detection task during the CPT, a motivated-distraction group performed the same task and received a monetary reward for good task performance, and a control group did not perform the tone-detection task. Results indicated that engagement in the distraction task was better in the motivated-distraction group in comparison with the distraction-only group. Participants in both distraction groups experienced less pain compared to the control group. There were no overall differences in pain intensity between the two distraction groups. The effect of distraction was influenced by the level of catastrophic thinking about pain. For low catastrophizers, both distraction groups reported less pain as compared to the non-distracted control group. This was not the case for high catastrophizers. For high catastrophizers it mattered whether the distraction task was motivationally relevant: high catastrophizers reported less intense pain in the motivated-distraction group, as compared to the non-distracted control group. We conclude that increasing the motivational relevance of the distraction task may increase the effects of distraction, especially for those who catastrophize about pain., (Copyright 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

The purpose of this meta-analytic review was to quantify the effects of psychological therapies for the management of chronic pain in youth. Specifically, in this review we updated previous systematic reviews of randomized controlled trials by including new trials, and by adding disability and emotional functioning to pain as treatment outcomes. Electronic searches of the Cochrane Register of Randomised Controlled Trials, MEDLINE, PsycLIT, EMBASE, and the Social Sciences Citation Index were conducted from inception through August 2008. Methodological quality of the studies was assessed, and data extracted on the three primary outcomes of interest. Twenty-five trials including 1247 young people met inclusion criteria and were included in the meta-analysis. Meta-analytic findings demonstrated a large positive effect of psychological intervention on pain reduction at immediate post-treatment and follow-up in youth with headache, abdominal pain, and fibromyalgia. Small and non-significant effects were found for improvements in disability and emotional functioning, although there were limited data on these outcomes available in the included studies. Omnibus cognitive-behavioral therapy, relaxation therapy, and biofeedback all produced significant and positive effects on pain reduction. Studies directly comparing the effects of self-administered versus therapist-administered interventions found similar effects on pain reduction. Psychological therapies result in improvement in pain relief across several different pain conditions in children. Future trials are needed that incorporate non-pain outcome domains, that focus significant therapeutic content on reductions in disability, and that include extended follow-up to better understand maintenance of treatment effects.

The selection of outcome criteria for chronic pain, both the domain of measurement and the magnitude of change, in RCTs is largely determined by the investigators. The present study investigated patient-determined criteria for the magnitude of change necessary to achieve an 'acceptable outcome' (endpoint) on the brief pain inventory and two subscales of the multidimensional pain inventory. Seventy-eight patients attending a chronic pain out-patient clinic were asked to rate their current state on the measures and then complete the scales as they would if treatment were to result in an acceptable outcome. The differences between the two sets of scores are described in terms of raw change scores, percentage change and by comparing the judgments of acceptable outcomes to statistically defined criteria (reliable change index and clinically significant change). Participants indicated a lower level of pain severity, impact and interference and a higher level of activity as part of an acceptable outcome. The degree of acceptable changes indicated by participants was higher (median values=44-75%) than the 30-50% typically reported as the threshold for clinically significant change for measures of pain experience in other studies. We also conducted tests of two models of change judgment. Neither adequately fit the data. There were discrepancies between the patients' judgments of acceptable outcomes and the RCI and SCS criteria. Suggestions for future research and possible clinical implications are discussed.

Randomized controlled trials and meta-analyses provide evidence for the efficacy of cognitive-behaviourally informed treatment (CBT) programmes for chronic pain. The current study aims to provide practice-based evidence for the effectiveness of CBT in routine clinical settings. Over a 10-year period 1013 pain patients were accepted into a 4 week in-patient pain management programme. Data from more than 800 patients was available at pre-treatment and at one month post-treatment and for around 600 patients at pre-treatment and at 9 months follow-up. Measures reported in this analysis were pain experience and interference, psychological distress (depression and anxiety), self-efficacy, catastrophizing, and walking. Change from pre-treatment to post-treatment and follow-up was assessed with conventional statistical tests, the computation of effect sizes and by the reliable change index (RCI) and clinically significant change (CSC) methodology. These analyses provide evidence of statistical improvement at post-treatment and follow-up and the RCI/CSC methodology suggested that between 1 in 3 and 1 in 7 (depending on the outcome measure) achieved clinically significant gains. There was also evidence that a small percentage of patients (1-2%) reliably deteriorated during the period of treatment. The limitations in the inferences that can be drawn from this study and of the methodology are discussed. A case is made for the application of benchmarking methods using data from RCTs in order to more fully evaluate practice and to generate better quality practice based evidence.

The aims of this study were to replicate and extend previous observations on the relationship between enmeshment of the self and pain and measures of adjustment [Morley et al., Possible selves in chronic pain: self-pain enmeshment, adjustment and acceptance, Pain 2005;115:84-94], and to test the hypothesis that individual variation in motivational preferences interacts with enmeshment. 82 chronic pain patients completed standardized self-report measures of depression, anxiety, acceptance and the possible selves interview which generated measures of their hoped-for (own and other perspectives) and feared-for selves. They made judgments about the conditionality of each self on the continuing presence of pain as a measure of self-pain enmeshment. A series of hierarchical regression analyses, that adjusted for demographics, pain characteristics and disability, confirmed the relationship between self enmeshment and depression and acceptance. When anxiety was considered, there was no main effect for any of the self aspects but there were specific interactions between the hoped-for (own) and (other) selves and two motivational preferences--autonomy and sociotropy.

Depression is a common feature of chronic pain, but there is only limited research into the content of depressed cognitions in pain patients. This study investigated the content of cognition in depressed pain patients, non-depressed pain patients, and two control groups, healthy controls, and osteopaths using a sentence completion task. Participants generated completed sentences to a set of predefined stems that included negative, positive and neutral self-reference, and past, future and world terms. Complete responses were coded by valence (negative, positive and neutral) and health/non-health related content. As predicted depressed pain patients produced more negative sentence completions to all stems than all other groups. Depressed pain patients produced more health related completions than either of the control groups. Pain patients who were not depressed did not differ from the osteopath control group in the number of health related completions. When negativity was considered depressed pain patients produced proportionately more negative health-related completions than all other groups. We suggest that the focus of depression in chronic pain patients is health related. Pain patients who are not depressed focus on health, but not necessarily in a negative way. The concept of themselves in the future might be a key aspect in depression in pain patients.

This paper reports the development of a scale for assessing the quality of reports of randomised controlled trials for psychological treatments. The Delphi method was used in which a panel of 15-12 experts generated statements relating to treatment and design components of trials. After three rounds, statements with high consensus agreement were reviewed by a second expert panel and rewritten as a scale. Evidence to support the reliability and validity of the scale is reported. Three expert and five novice raters assessed sets of 31 and 25 published trials to establish scale reliability (ICC ranges from 0.91 to 0.41 for experts and novices, respectively) and item reliability (Kappa and inter-rater agreement). The total scale score discriminated between trials globally judged as good and poor by experts, and trial quality was shown to be a function of year of publication. Uses for the scale are suggested.

The aim of this study was to test whether enmeshment of self and pain predicted adjustment (depression and acceptance) in a chronic pain population. 89 chronic pain patients completed standardized self-report measures of depression and acceptance and generated characteristics describing their current actual self, hoped-for self and feared-for self, and made judgments about the degree to which their future possible selves (hoped-for and feared-for) were dependent on the absence or presence of pain, i.e. enmeshed with pain. Hierarchical multiple regression analyses showed that after accounting for the influence of demographics (age, gender), pain characteristics and the degree of role interference attributable to pain, the proportion of hoped-for self characteristics that could be achieved even with the presence of pain predicted the magnitude of depression and acceptance scores. The findings are discussed with reference to the enmeshment hypothesis and theories of self-discrepancy, self-regulation and hopelessness.

Chronic pain interrupts behaviour, interferes with functioning, and may affect a person's identity: their sense of self. We tested whether loss of role and personal attributes and current and past self-concept differentiation, predicted adjustment as indexed by measures of depression. Chronic pain patients (n=80) completed measures of pain (MPQ), disability (PDI), depression and anxiety (BDI, HADS). Measures of role and attribute loss and self-concept differentiation were derived from a Role-Attribute Test in which participants identified four social roles in four domains (friendship, occupation, leisure, family) and nominated two personal attributes in each role prior to pain onset and current. Participants reported mean losses of 3.38 roles, and 6.97 attributes. Greater losses were observed in friendship, occupation and leisure domains compared with the family domain. Multiple regression analyses revealed that after controlling for demographic and clinical differences, role and attribute loss predicted depression scores. There was no evidence that depression was associated with past self-concept differentiation. The results are discussed with reference to the methodology used and the relevance of self-identity to understand adjustment to chronic pain.

The Beck Depression Inventory (BDI) is widely used to assess depression in chronic pain despite doubts about its structure and therefore its interpretation. This study used a large sample of 1947 patients entering chronic pain management to establish the structure of the BDI. The sample was randomly divided to conduct separate exploratory (EFA) and confirmatory factor analyses (CFA). EFA produced many satisfactory two-factor solutions. The series of CFA generated showed reasonable fit for ten of those solutions. All included a first factor identified as negative view of the self (items: failure, guilt, self-blame, self-dislike, punishment and body image change), and a second factor identified as somatic and physical function (items: work difficulty, loss of appetite, loss of libido, fatigability, insomnia and somatic preoccupation). The remaining items (suicidal ideation, social withdrawal, dissatisfaction, sadness, pessimism, crying, indecisiveness, weight loss, irritability) loaded infrequently or not at all in the CFA solutions. They did not form a coherent factor but comprised items associated with negative affect. When compared with published data from samples of depressed patients drawn from mental health settings the mean item scores for items reflecting the negative view of the self were consistently statistically lower that that observed in samples; there was no consistent difference between the samples on the items reflecting somatic and physical function; but the mean scores for the remaining affect items were significantly greater in the mental health samples. This version of depression is strikingly different from the psychiatric model of depression (e.g. DSM-IV or ICD-10), which is primarily defined by affective disturbance, and secondarily supported by cognitive and somatic symptoms. The finding is consistent with a reconsideration of what constitutes depression in the presence of chronic pain. It also has important clinical implications: it may provide a way to distinguish depressed patients with typical cognitive biases, who require specific treatment for depression alongside pain management., (Copyright 2002 International Association for the Study of Pain)

A systematic review and subset meta-analysis of published randomised controlled trials of psychological therapies for children and adolescents with chronic pain is reported. A search of four computerised abstracting services recovered 123 papers from which 28 potential trials were identified. Eighteen met the criteria for inclusion in the review. The majority of these papers reported brief behavioural and cognitive behavioural interventions for children with headache and many were conducted in community (i.e. school) settings. Meta-analysis was applicable for 12 headache trials and one trial of recurrent abdominal pain using the Pain Index. The odds-ratio for a 50% reduction in pain was 9.62 and the number needed to treat was 2.32, indicating that the psychological treatments examined are effective in reducing the pain of headache. The quality of the 18 trials retrieved is narratively reviewed and suggestions for the development of trials in this field are made., (Copyright 2002 International Association for the Study of Pain)

In the first part of the study 20 subjects (11 headache, 9 normals) free-sorted descriptors from the intensity and affect scales of the Tursky pain perception profile (PPP) into groups on the basis of similar meaning. In part 2 they made similarity ratings of all pairs of words within the intensity and affect scales. In the third part of the study subjects completed a cross-modal matching task to scale the intensity and affect words. Data from the first 2 parts of the study were examined with multidimensional scaling (MDS) and hierarchical cluster analyses. Free-sorting the descriptors did not produce 2 groups corresponding to the intensity and affect descriptors described in the Tursky PPP. The descriptors were arranged in 6 groups described by subjects as reflecting increasing painfulness. An MDS analysis showed that the groups could be located in 2-dimensional space in which the dimensions of intensity and affective distress could be easily discerned. When the descriptors from the intensity and affect scales were rated within each scale, a second MDS analysis showed that, whereas the intensity descriptors could be fitted by a 1-dimensional representation, the affect descriptors required a 3-dimensional model. There was evidence that subjects with extensive pain experience placed greater weight on the second and third affective dimensions compared with relatively pain-free subjects.

101 subjects engaged in a self-administered cross-modal matching task to scale descriptors of pain intensity and unpleasantness. The correlation between the two responses was used to determine reliability (internal consistency). When r greater than or equal to 0.90 was set as a criterion about 3% of the subjects were unable to calibrate standard stimuli reliability, 6% were unable to calibrate intensity descriptors and 60% were unable to calibrate unpleasantness descriptors reliably. When the criterion reliability was set at r greater than or equal to 0.85 all subjects successfully scaled the intensity descriptors. Further relaxation of the criterion to r greater than or equal to 0.80 reduced the 'failure' rate for unpleasantness descriptors to 24%. These data compare favourably with other published results from non-chronic and chronic pain patients. The provision of a fixed reference value produced range effects in the resulting scale but do not severely attenuate the range of the scale as has been previously suggested. It is concluded that a self-administered version of the task is feasible. Reasons for the poor performance with the unpleasantness descriptors are discussed.