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BACKGROUND: Although pain-related avoidance is mainly intended to reduce the accompanying anticipatory fear, avoidance behavior may paradoxically increase fear when a previous avoidance response is no longer available, suggesting that there is a bidirectional relationship between pain-related fear and avoidance.PURPOSE: We hypothesized that avoidance can serve as a source of information that fuels irrational pain-related threat appraisals, which, in turn, increases pain-related fear.METHODS: Participants (N = 66) were exposed to a painful heat stimulus and randomly assigned to the avoidance or control group. They were instructed to avoid the full heat intensity by pressing a stop button in the presence of a stop cue. Only avoidance group participants received a stop cue and were allowed to press the stop button, while control group participants received the same instructions but never had the opportunity to avoid the full heat intensity. In reality and unknown to participants, the intensity and duration of the heat stimulus was independent of the avoidance response. In the subsequent test phase, the avoidance response was unavailable for both groups. We measured pain-related fear, threat appraisals/harmfulness, and pain intensity.RESULTS: In line with our expectations, pain-related fear levels were higher when the avoidance response was no longer available compared to those when the avoidance response was available. Increased threat appraisals mediated the relationship between avoidance behavior and increased pain-related fear.CONCLUSIONS: The perceived opportunity to avoid increased pain-related fear through threat appraisals, suggesting a more complicated relationship between pain-related fear, threat appraisals, and avoidance behavior than the unidirectional relationships proposed in the fear-avoidance model. Clinical implications are discussed.

The fear-avoidance model of chronic pain predicts that catastrophic (mis)interpretation of pain elicits pain-related fear that in turn may spur avoidance behaviour leading to chronic pain disability. Here, we investigated whether performing a movement to avoid a painful stimulus in the context of a novel movement increases threat and pain-related fear towards this novel movement and whether avoidance behaviour persisted when given the choice between performing the acquired movement to avoid a painful stimulus or an alternative, novel movement. Applying a robotic arm-reaching task, participants could choose between 2 movements to reach a target location: a short, but painful movement trajectory, or a longer nonpainful movement trajectory. After avoidance acquisition, the option to choose the painful trajectory was removed. The experimental group (N = 50) could choose between the longest trajectory or a novel intermediate trajectory, whereas the control group (N = 50) was allowed to only perform the novel trajectory. In a final test, participants of both groups were allowed to choose any of the 3 trajectories. After acquisition, experimental group participants showed elevated pain expectancy and pain-related fear towards the novel trajectory, compared with the control group. During test, the experimental group participants persisted in performing the longest pain-free (avoidance) trajectory and were less likely to choose the novel trajectory. In addition, these participants maintained higher levels of pain-related fear for the novel trajectory compared with the control group. These findings suggest that avoidance in the context of other neutral activities/movements may lead to the development and maintenance of threat appraisals and irrational fears.

Objective: Numerous provocations cause aggressive behavior. However, different provocation procedures are rarely directly compared. This study examined whether two different provocations (i.e., social exclusion and insult) were equally effective in terms of producing aggressive behavior, negative affective change and threat perception. As psychopathic and narcissistic personality traits may moderate provoked aggression, the current study also explored the differential impact of psychopathic and narcissistic traits on these variables. Method: A male (N = 94) community sample was randomly allocated to receive negative social belonging feedback (i.e., social exclusion) or negative intelligence feedback (i.e., insult) by a confederate. Aggressive behavior was measured using a competitive reaction time task after provocation. Here, aggressive behavior before first provocation (i.e., noise blast) by the opponent reflected unprovoked aggression, whereas aggressive behavior after first provocation reflected provoked aggression. Negative affect was measured pre- and postprovocation, and threat perception was measured postprovocation. Results: Results showed that both provocations were equally effective in producing aggressive behavior, negative affective change, and threat perception. Explorative analysis revealed that increased threat perception suppresses initial aggressive responding under the condition of agentic threat in narcissistic people. Also, decreased negative affective change during provocation suppressed aggressive responding in people with psychopathic traits. Conclusions: The findings suggest that both provocations can interchangeably be implemented to study provoked aggression. Emotional blunting may protect against detrimental provocation effects in people with psychopathic traits. Under conditions of agentic threat narcissistic traits related to withholding aggressive responding after first provocation, lashing out when a new threat emerges.

Avoidance is considered key in the development of chronic pain. However, little is known about how avoidance behaviour subsequently affects pain-related fear and pain. We investigated this using a robotic arm reaching avoidance task to investigate this. In a between-subjects design both Experimental Group (n=30) and Yoked Control Group (n=30) participants perform either of three movement trajectories (T1-T3) to reach a target location. During acquisition, only participants of the Experimental Group could partially or fully avoid a painful electrocutaneous stimulus by choosing the intermediate trajectory (T2; 50% reinforcement) or the longest trajectory (T3; 0% reinforcement) versus the shortest trajectory (T1: 100% reinforcement). After acquisition, contingencies changed (all trajectories 50% reinforced), and the acquired avoidance behaviour no longer effectively prevented pain from occurring. The Yoked Control Group received the same reinforcement schedule as the Experimental Group irrespective of their behaviour. When avoidance behaviour became ineffective for the Experimental Group, pain-related fear increased for the previously safe(r) trajectories (T2 and T3) and remained the same for T1, whereas pain threshold and tolerance declined. For the Yoked Group, pain-related fear increased for all trajectories. The Experimental Group persisted in emitting avoidance behaviour following the contingency change, albeit at a lower frequency than during acquisition. PERSPECTIVE: Results indicate participants become more afraid of and sensitive to pain, when previously acquired avoidance is no longer effective. Also, participants continue to show avoidance behaviour despite it being not adaptive anymore. These findings suggest that ineffective avoidance may play role in the maintenance and development of chronic pain.

Background: Effects of emotion suppression on physical health might be contingent on culture. Existing research on emotion regulation has mainly included western participants. Herewith the question arises, whether this gained expertise is transferable to an Asian culture. Objectives: This cross-sectional study evaluated to what extent the regulation of emotions is related to migraine and if the relation between emotion regulation and migraine complaints differs between a Western and an Asian population. Therefore, the main characteristics and symptoms of patients with migraine from both Germany and Japan are compared. Methods: 261 Japanese and 347 German headache patients participated in this online study and completed self-report measures of emotion regulation (suppression and reappraisal) and headache complaints. Results: Cultural groups did not differ regarding their demographic data, intake of medication and number of days with headache. German participants showed significantly higher levels of anxiety and lower levels of emotion suppression compared to Japanese patients. Emotion regulation is not correlated with headache complaints either in the Japanese or in the German patient group. Conclusion: Although group differences were found with respect to anxiety and emotion suppression, subsequent regression analysis revealed these differences were unrelated to headache complaints. As our baseline analysis focused on group means, approaches that examine individual reaction patterns to stress and accompanying sensory stimulus processing may prove to be more fruitful and illuminating.

BACKGROUND AND OBJECTIVES: Amongst social contextual influences on pain, the manner in which pain and painful procedures are communicated to patients is considered an important contributor to the subjective experience of pain. Threatening information, e.g., by the use of technical language, is suggested to increase pain reports. Validation, or communicating understanding towards another person reporting personal experiences, is suggested to reduce pain. The current study examines effects of both information language (technical vs. plain language) and validation (validation vs. invalidation) on the subjective experience of experimentally induced pain.METHODS: Pain-free participants (N = 132) were randomly assigned to one of four groups as formed by manipulations of validation and information language. After reading a description concerning the upcoming thermal stimulus formulated in technical or plain language, participants engaged in a computer controlled simulation (CCS; based on virtual reality technology). Participants received three thermal stimuli while interacting with an avatar who either validated or invalidated their experience during the CCS. Pain intensity and pain unpleasantness were assessed after each stimulus.RESULTS: The validation manipulation showed to be effective, but the information language manipulation did not induce differential threat expectancies. Results show no effect of validation or information language on subjective pain reports.LIMITATIONS: Suboptimality of the information language manipulation and shortcomings of the CCS procedure might account for current findings.CONCLUSIONS: The study offers an interesting model for the further experimental study of isolated and combined effects of (social) contextual factors on pain. Diverse future research avenues are discussed.

Background and aims: Interpreting pain- and illness-related stimuli as health-threatening is common among chronic pain patients but also occurs in the general population. As interpretation bias (IB) may affect pain perception and might even play part in the development and maintenance of chronic pain, it is important to improve our understanding of this concept. Several studies suggest an association between IB and pain- related anxiety. However, those studies often rely on verbal and pictorial IB tasks that do not entail a threat of actual pain, therefore lacking personal relevance for healthy participants. The current study investigated whether healthy individuals show an IB towards ambiguous health-related stimuli in a context of actual pain threat, and explored whether this bias is associated to pain anxiety constructs. Methods: Thirty-six healthy participants were conditioned to expect painful electrocutaneous shocks (unconditioned stimulus - US) after health-threat words (CS+) but not after neutral (non-health-threat) words (CS-) in order to establish fear of pain. Subsequently, they completed a verbal interpretation task that contained new CS+ and CS- stimuli as well as ambiguous non-reinforced health-threat and non-health-threat words. IB was assessed through shock expectancy ratings and startle responses to ambiguous and evident health threatening or neutral word stimuli. Pain-related anxiety was measured with validated questionnaires. Results: The results show a general IB towards ambiguous health-related words on pain expectancies but not on startle response. An exploratory analysis suggests that this effect exists irrespective of pain-related anxiety levels which however may be due to a lack of power. Conclusion: We present a novel experimental paradigm employing actual health threat that captures IB towards health-related stimuli in healthy individuals. Taken together, results provide evidence for the further consideration of IB as a latent

Fear-avoidance models propose that pain-related fear may spur avoidance behaviour leading to chronic pain disability. Pain-related fear elicits avoidance behaviour, which is typically aimed at reducing fear. We hypothesized that engaging in avoidance may (paradoxically) increase rather than decrease pain-related fear (i.e. bidirectionality hypothesis). In a between-subject design, participants (N=64) were randomly assigned to the avoidance group or the control group. Avoidance group participants were led to believe they could avoid full exposure to a painful heat stimulus by pressing the stop-button, while control group participants believed they were exposed to the full painful heat stimulus at all times. In reality and unknown to the participants, the intensity and duration of the heat stimulus was independent of the avoidance response, and was identical in both groups. During the test, the avoidance response (i.e. pressing the stop-button) was no longer available. As expected, pain-related fear levels were higher after avoiding the painful heat stimulus. Interestingly, in the avoidance group, pain-related fear increased after receiving instructions that avoidance would be possible, even before actually engaging in avoidance behaviour. In the control group, no significant change was observed in pain-related fear throughout the experiment. The eyeblink startle measures did not corroborate this data pattern.PERSPECTIVE: These observations provide partial support for the bidirectionality hypothesis between avoidance behaviour and fear. These findings may have clinical implications and suggest that allowing avoidance behaviours during treatment may thwart fear reduction.

BACKGROUND AND AIMS: Interrupting ongoing activities with the intention to resume them again later is a natural response to pain. However, such interruptions might have negative consequences for the subsequent resumption and performance of the interrupted activity. Activity interruptions by pain may be more impairing than interruptions by non-painful stimuli, and also be subjectively experienced as such. These effects might be more pronounced in people high in pain catastrophizing. These hypotheses were investigated in two experiments.METHODS: In Experiment 1, healthy volunteers (n=24) performed an ongoing task requiring a sequence of joystick movements. Occasionally, they received either a painful electrocutaneous or a non-painful vibrotactile stimulus, followed by suspension of the ongoing task and temporary engagement in a different task (interruption task). After performing the interruption task for 30s, participants resumed the ongoing task. As the ongoing task of Experiment 1 was rather simple, Experiment 2 (n=30) included a modified, somewhat more complex version of the task, in order to examine the effects of activity interruptions by pain.RESULTS: Participants made more errors and were slower to initiate movements (Experiment 1 & 2) and to complete movements (Experiment 2) when they resumed the ongoing task after an interruption, indicating that interruptions impaired subsequent performance. However, these impairments were not larger when the interruption was prompted by painful than by non-painful stimulation. Pain catastrophizing did not influence the results.CONCLUSIONS: Results indicate that activity interruptions by pain have negative consequences for the performance of an activity upon its resumption, but not more so than interruptions by non-painful stimuli. Potential explanations and avenues for future research are discussed.IMPLICATIONS: Interrupting ongoing activities is a common response to pain. In two experime

Persistent pain can lead to difficulties in executive task performance. Three core executive functions that are often postulated are inhibition, updating, and shifting. Optimism, the tendency to expect that good things happen in the future, has been shown to protect against pain-induced performance deterioration in executive function updating. This study tested whether this protective effect of a temporary optimistic state by means of a writing and visualization exercise extended to executive function shifting. A 2 (optimism: optimism vs no optimism) x 2 (pain: pain vs no pain) mixed factorial design was conducted. Participants (N = 61) completed a shifting task once with and once without concurrent painful heat stimulation after an optimism or neutral manipulation. Results showed that shifting performance was impaired when experimental heat pain was applied during task execution, and that optimism counteracted pain-induced deterioration in task-shifting performance.Perspective: Experimentally-induced heat pain impairs shifting task performance and manipulated optimism or induced optimism counteracted this pain-induced performance deterioration. Identifying psychological factors that may diminish the negative effect of persistent pain on the ability to function in daily life is imperative. (C) 2016 by the American Pain Society

BACKGROUND AND AIMS: Interrupting ongoing activities with the intention to resume them again later is a natural response to pain. However, such interruptions might have negative consequences for the subsequent resumption and performance of the interrupted activity. Activity interruptions by pain may be more impairing than interruptions by non-painful stimuli, and also be subjectively experienced as such. These effects might be more pronounced in people high in pain catastrophizing. These hypotheses were investigated in two experiments. METHODS: In Experiment 1, healthy volunteers (n=24) performed an ongoing task requiring a sequence of joystick movements. Occasionally, they received either a painful electrocutaneous or a non-painful vibrotactile stimulus, followed by suspension of the ongoing task and temporary engagement in a different task (interruption task). After performing the interruption task for 30s, participants resumed the ongoing task. As the ongoing task of Experiment 1 was rather simple, Experiment 2 (n=30) included a modified, somewhat more complex version of the task, in order to examine the effects of activity interruptions by pain. RESULTS: Participants made more errors and were slower to initiate movements (Experiment 1 & 2) and to complete movements (Experiment 2) when they resumed the ongoing task after an interruption, indicating that interruptions impaired subsequent performance. However, these impairments were not larger when the interruption was prompted by painful than by non-painful stimulation. Pain catastrophizing did not influence the results. CONCLUSIONS: Results indicate that activity interruptions by pain have negative consequences for the performance of an activity upon its resumption, but not more so than interruptions by non-painful stimuli. Potential explanations and avenues for future research are discussed. IMPLICATIONS: Interrupting ongoing activities is a common response to pain. In two experiments using a novel paradigm, Funding Agency:Research Foundation - Flanders, Belgium (FWO Vlaanderen) PSG-C5007-Asp/12

Background/aims: Pain can interrupt and deteriorate executive task performance. We have previously shown that experimentally induced optimism can diminish the deteriorating effect of cold pressor pain on a subsequent working memory task (i.e., operation span task). In two successive experiments we sought further evidence for the protective role of optimism on pain-induced working memory impairments. We used another working memory task (i.e., 2-back task) that was performed either after or during pain induction. Methods: Study 1 employed a 2 (optimism vs. no-optimism) x 2 (pain vs. no-pain) x 2 (pre-score vs. post score) mixed factorial design. In half of the participants optimism was induced by the Best Possible Self (BPS) manipulation, which required them to write and visualize about a life in the future where everything turned out for the best. In the control condition, participants wrote and visualized a typical day in their life (TD). Next, participants completed either the cold pressor task (CPT) or a warm water control task (WWCT). Before (baseline) and after the CPT or WWCT participants working memory performance was measured with the 2-back task. The 2-back task measures the ability to monitor and update working memory representation by asking participants to indicate whether the current stimulus corresponds to the stimulus that was presented 2 stimuli ago. Study 2 had a 2 (optimism vs. no-optimism) x 2 (pain vs. no-pain) mixed factorial design. After receiving the BPS or control manipulation, participants completed the 2-back task twice: once with painful heat stimulation, and once without any stimulation (counterbalanced order). Continuous heat stimulation was used with temperatures oscillating around 1 C above and 1 C below the individual pain threshold. Results: In study 1, the results did not show an effect of cold pressor pain on subsequent 2-back task performance. Results of study 2 indicated that heat pain impaired concurrent 2-back task performance.

Individuals with pain-related concerns are likely to interpret ambiguous pain-related information in a threatening manner. It is unknown whether this interpretation bias also occurs for ambiguous pain-related facial expressions. This study examined whether individuals who habitually attach a catastrophic meaning to pain are characterized by negative interpretation bias for ambiguous pain-related facial expressions. Sixty-four female undergraduates completed an incidental learning task during which pictures of faces were presented, each followed by a visual target at one of two locations. Participants indicated target location by pressing one of two response keys. During the learning phase, happy and painful facial expressions predicted target location. During two test phases, morphed facial expressions of pain and happiness were added, equally often followed by a target at either location. Faster responses following morphs to targets at the location predicted by painful expressions compared to targets at the location predicted by happy expressions were taken to reflect pain-related interpretation bias. During one test phase, faces were preceded by either a safe or threatening context cue. High, but not low, pain-catastrophizers responded faster following morphs to targets at the location predicted by painful expressions than to targets at the other location (when participants were aware of the contingency between expression type and target location). When context cues were presented, there was no indication of interpretation bias. Participants were also asked to directly classify the facial expressions that were presented during the incidental learning task. Participants classified morphs more often as happy than as painful, independent of their level of pain catastrophizing. This observation is discussed in terms of differences between indirect and direct measures of interpretation bias.

Chronic musculoskeletal pain syndromes are responsible for enormous costs for healthcare and society (Linton 1998; Phillips et al. 2008; Picavet and Schouten 2003; Verhaak et al. 1998). Nowadays, the biopsychosocial perspective on pain offers a good foundation for a better insight into how pain can become a persistent problem (Fordyce 1976>; Turk and Flor 1999). In this perspective, pain and pain disability are influenced by the dynamic interaction among biological, psychological, and social factors. The present chapter focuses on the role of fear and avoidance in the development and maintenance of chronic low back pain (CLBP). In the following paragraphs, an overview on the aetiology of low back pain (LBP), the conceptualization of fear and avoidance, and the development of fear-avoidance models will be provided. Furthermore, empirical evidence on the role of fear and avoidance behaviour in chronic pain, stemming from studies conducted in pain patients and in healthy volunteers, will be reviewed. This chapter will then continue with a discussion on how to assess fear of pain both at a direct and indirect level. Finally, this chapter will end with perspectives on the cognitive-behavioural management of chronic pain in patients who are characterized by increased pain-related fear and avoidance behaviour.