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OBJECTIVES: Tinnitus is the perception of sound without an external source, affecting quality of life that can cause severe distress in approximately 1 to 3% of the population of people with tinnitus. Randomized controlled trials of cognitive behavioral therapy for tinnitus have demonstrated its effectiveness in improving quality of life, but the effects of their implementation on a large scale in routine practice remains unknown. Therefore, the main purpose of this study was to examine the effects of stepped-care cognitive behavioral therapy for tinnitus delivered in a tertiary audiological center of a regional hospital. Second, we wished to examine predictors of favorable outcome. DESIGN: Four hundred three adults with chronic tinnitus were enrolled in this prospective observational study (at 3 months, N=334, 8 months, N=261; 12 months, N=214). The primary outcome was health-related quality of life as measured by the Health Utilities Index III (HUI-III) at 12 months. Secondary outcomes were self-reported levels of tinnitus-related distress, disability, affective distress and tinnitus-related negative beliefs and fear. Measures were completed pre-intervention at 3 months, 8 months, and 12 months. Multilevel modeling was used to examine effects and their predictors. RESULTS: Younger participants with lower levels of tinnitus distress were more likely to dropout while those with higher tinnitus distress at baseline and quality of life were more likely to receive step 2 of treatment. MLM analyses revealed, with one exception, no relation between any baseline variable and outcome change over time. Most participants' improvement exceeded minimally clinical important difference criteria for quality of life, tinnitus-related handicap, and tinnitus distress. CONCLUSIONS: Results from this large pragmatic study complements those from randomized controlled trials of cognitive behavioral therapy for chronic tinnitus distress and supports its implementation under "real-world" conditions. ispartof: Ear And Hearing vol:43 issue:6 pages:1-11 ispartof: location:United States status: Published online

Despite being unpleasant, acute pain has a functional role in our lives. Pain serves as a warning signal that pushes to actions preventing additional harm (e.g., instantly lifting the foot after stepping on a thorn). Pain becomes problematic when it becomes chronic. Chronic pain is associated with reduced quality of life for patients and elevated monetary costs for individuals and society in general (Dagenais, Caro, & Haldeman, 2008; Yong et al., 2022). One way to better understand the transition between acute to chronic pain is to look into decision-making, and more specifically into the exploration-exploitation dilemma (EED). The EED is a dilemma that opposes the choice of familiar options (i.e., exploitation) with known outcomes to new ones with their risks (i.e., exploration). In a pain context, over-exploring could lead to unnecessary pain (e.g., worsening an injury in the ankle by running a marathon). On the other hand, overexploiting alternatives leading to the least pain (e.g., stopping running definitively) could create a cycle of pain-related avoidance as exploration is needed to correct wrong threat beliefs about pain (e.g., the ankle pain is no more present) (Vlaeyen, Crombez, & Linton, 2016) Investigating how people decide to explore or exploit and how individual differences influence these decisions can help understanding better chronic pain. In the current study, we propose studying behavioral persistence during the EED in the control and clinical group (i.e., healthy individuals and individuals experiencing chronic pain) and the role of individual differences in this trade-off. This study has been approved by Ethics Committee of KU Leuven (#G 2023-6568-R4-(MIN)).

According to limited-capacity theories, the processing of nociceptive stimuli may be reduced when less attentional resources are available, which may diminish the development of secondary hypersensitivity, i.e. the increased sensitivity to mechanical pinprick stimuli applied in the uninjured area. In this study, we used Low Frequency Stimulation (LFS) to examine the contributions of cognitive load, its modulation by sex, and sympathetic arousal to the development of hypersensitivity. Eighty-four healthy participants were randomized into a low and a high load group. Before, during, and after LFS, participants executed a low or a high cognitive demanding task. Meanwhile we recorded Steady State Evoked potentials (SSEPs) evoked by LFS as proxy for attentional capture, and skin conductance level (SCL) for sympathetic arousal. After the task, participants reported task difficulty and pain-related fear. The perceived intensity and unpleasantness of mechanical pinprick stimulation was assessed before and after LFS. Although the load manipulation was successful, we did not find significant group and sex differences in perceived intensity and unpleasantness of mechanical pinpricks and SSEPs power. Notwithstanding a lack of group differences in SCL, we observed a negative correlation between SCL before LFS and hypersensitivity, whereas pain-related fear was positively correlated with perceived intensity and unpleasantness of mechanical pinpricks. These results do not support the hypotheses that cognitive load and sex modulate hypersensitivity, but show associations with pain-related fear and non-pain related sympathetic arousal.

This article describes a proposal for the new diagnosis of chronic primary pain (CPP) in ICD-11. Chronic primary pain is chosen when pain has persisted for more than 3 months and is associated with significant emotional distress and/or functional disability, and the pain is not better accounted for by another condition. As with all pain, the article assumes a biopsychosocial framework for understanding CPP, which means all subtypes of the diagnosis are considered to be multifactorial in nature, with biological, psychological, and social factors contributing to each. Unlike the perspectives found in DSM-5 and ICD-10, the diagnosis of CPP is considered to be appropriate independently of identified biological or psychological contributors, unless another diagnosis would better account for the presenting symptoms. Such other diagnoses are called “chronic secondary pain” where pain may at least initially be conceived as a symptom secondary to an underlying disease. The goal here is to create a classification that is useful in both primary care and specialized pain management settings for the development of individualized management plans, and to assist both clinicians and researchers by providing a more accurate description of each diagnostic category. ispartof: PAIN vol:160 issue:1 pages:28-37 ispartof: location:United States status: published

Background and aims In the spring of 2019, Professor Steven J. Linton, the founder of the Center for Health and Medical Psychology (CHAMP) at Örebro University, Sweden, formally retired. As a tribute to his scholarly work covering decades of influence and inspiration to the field of pain psychology, the research center organized a topical conference titled "Pain in the 21st century: Where do we come from and where are we going?", which resulted in this state-of the-art synthesis. The aim of this declaration is to highlight lessons learned but not in the least is meant to inspire and guide our continued journey forward, developing pain psychology into the 21st century. Methods Several collaborators of Professor Linton have summarized and reflected on the current state-of-the-art of pain psychology from the perspective of his input to the field, as well as on developments from the last years of advancements in pain psychology. Results The topics have been divided into six themed sections covering the fear avoidance model, transdiagnostics, secondary prevention, risk- and protective factors, communication and contextual factors. The sections cover a broad spectrum, from basic experimental studies, integrating emotion and motivational theories into current theoretical models, to applied research on the effect of early interventions as well as sophisticated emotion-focused treatment models for pain patients with concurrent emotional ill-health. Conclusions There have been major advancements within pain psychology research during the last decades, moving the field towards a more comprehensive picture, taking emotional and motivational aspects into account to understand pain sufferers. Although psychologically informed interventions in general mainly focus on the individual, it has been put forward that pain management is highly influenced by the surrounding environment, including communication with health care providers, and the occupational and social context. Implications Professor Steven J. Linton has been at the forefront of pain psychology research during the last decades, and inspired by his work this journey will continue into the 21st century, with the ultimate goal of enhancing the understanding and treatment for all people suffering from persistent and disabling pain. ispartof: Scandinavian Journal of Pain vol:20 issue:2 pages:229-238 ispartof: location:Germany status: published

ispartof: Psykologtidningen vol:2 pages:30-33 status: published

BACKGROUND: Tinnitus affects up to 21% of the adult population with an estimated 1% to 3% experiencing severe problems. Cognitive behavioural therapy (CBT) is a collection of psychological treatments based on the cognitive and behavioural traditions in psychology and often used to treat people suffering from tinnitus. OBJECTIVES: To assess the effects and safety of CBT for tinnitus in adults. SEARCH METHODS: The Cochrane ENT Information Specialist searched the ENT Trials Register; CENTRAL (2019, Issue 11); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 25 November 2019. SELECTION CRITERIA: Randomised controlled trials (RCTs) of CBT versus no intervention, audiological care, tinnitus retraining therapy or any other active treatment in adult participants with tinnitus. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. Our primary outcomes were the impact of tinnitus on disease-specific quality of life and serious adverse effects. Our secondary outcomes were: depression, anxiety, general health-related quality of life, negatively biased interpretations of tinnitus and other adverse effects. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS: We included 28 studies (mostly from Europe) with a total of 2733 participants. All participants had had tinnitus for at least three months and their average age ranged from 43 to 70 years. The duration of the CBT ranged from 3 to 22 weeks and it was mostly conducted in hospitals or online. There were four comparisons and we were interested in outcomes at end of treatment, and 6 and 12 months follow-up. The results below only refer to outcomes at end of treatment due to an absence of evidence at the other follow-up time points. CBT versus no intervention/wait list control Fourteen studies compared CBT with no intervention/wait list control. For the primary outcome, CBT may reduce the impact of tinnitus on quality of life at treatment end (standardised mean difference (SMD) -0.56, 95% confidence interval (CI) -0.83 to -0.30; 10 studies; 537 participants; low certainty). Re-expressed as a score on the Tinnitus Handicap Inventory (THI; range 0 to 100) this is equivalent to a score 10.91 points lower in the CBT group, with an estimated minimal clinically important difference (MCID) for this scale being 7 points. Seven studies, rated as moderate certainty, either reported or informed us via personal communication about serious adverse effects. CBT probably results in little or no difference in adverse effects: six studies reported none and in one study one participant in the CBT condition worsened (risk ratio (RR) 3.00, 95% CI 0.13 to 69.87). For the secondary outcomes, CBT may result in a slight reduction in depression (SMD -0.34, 95% CI-0.60 to -0.08; 8 studies; 502 participants; low certainty). However, we are uncertain whether CBT reduces anxiety, improves health-related quality of life or reduces negatively biased interpretations of tinnitus (all very low certainty). From seven studies, no other adverse effects were reported (moderate certainty). CBT versus audiological care Three studies compared CBT with audiological care. CBT probably reduces the impact of tinnitus on quality of life when compared with audiological care as measured by the THI (range 0 to 100; mean difference (MD) -5.65, 95% CI -9.79 to -1.50; 3 studies; 444 participants) (moderate certainty; MCID = 7 points). No serious adverse effects occurred in the two included studies reporting these, thus risk ratios were not calculated (moderate certainty). The evidence suggests that CBT may slightly reduce depression but may result in little or no difference in anxiety or health-related quality of life (all low certainty) when compared with audiological care. CBT may reduce negatively biased interpretations of tinnitus when compared with audiological care (low certainty). No other adverse effects were reported for either group (moderate certainty). CBT versus tinnitus retraining therapy (TRT) One study compared CBT with TRT (including bilateral sound generators as per TRT protocol). CBT may reduce the impact of tinnitus on quality of life as measured by the THI when compared with TRT (range 0 to 100) (MD -15.79, 95% CI -27.91 to -3.67; 1 study; 42 participants; low certainty). For serious adverse effects three participants deteriorated during the study: one in the CBT (n = 22) and two in the TRT group (n = 20) (RR 0.45, 95% CI 0.04 to 4.64; low certainty). We are uncertain whether CBT reduces depression and anxiety or improves health-related quality of life (low certainty). CBT may reduce negatively biased interpretations of tinnitus. No data were available for other adverse effects. CBT versus other active control Sixteen studies compared CBT with another active control (e.g. relaxation, information, Internet-based discussion forums). CBT may reduce the impact of tinnitus on quality of life when compared with other active treatments (SMD -0.30, 95% CI -0.55 to -0.05; 12 studies; 966 participants; low certainty). Re-expressed as a THI score this is equivalent to 5.84 points lower in the CBT group than the other active control group (MCID = 7 points). One study reported that three participants deteriorated: one in the CBT and two in the information only group (RR 1.70, 95% CI 0.16 to 18.36; low certainty). CBT may reduce depression and anxiety (both low certainty). We are uncertain whether CBT improves health-related quality of life compared with other control. CBT probably reduces negatively biased interpretations of tinnitus compared with other treatments. No data were available for other adverse effects. AUTHORS' CONCLUSIONS: CBT may be effective in reducing the negative impact that tinnitus can have on quality of life. There is, however, an absence of evidence at 6 or 12 months follow-up. There is also some evidence that adverse effects may be rare in adults with tinnitus receiving CBT, but this could be further investigated. CBT for tinnitus may have small additional benefit in reducing symptoms of depression although uncertainty remains due to concerns about the quality of the evidence. Overall, there is limited evidence for CBT for tinnitus improving anxiety, health-related quality of life or negatively biased interpretations of tinnitus. ispartof: Cochrane Database Of Systematic Reviews vol:1 issue:1 ispartof: location:England status: Published online

ispartof: The Journal of Pain vol:12 issue:2 pages:304-305 ispartof: location:United States status: published

ispartof: Quality of Life Research vol:9 issue:3 pages:304-304 status: published

Contemporary biopsychosocial models of chronic pain, such as the fear-avoidance model (Vlaeyen et al., 2016; Vlaeyen and Linton, 2012, 2000), posit that pain-related fear plays a pivotal role in the development and maintenance of the disability experienced by patients. Yet, as discussed in Chapter 1, our knowledge of the neuro-cognitive mechanisms underlying pain-related fear is limited. This led us to develop an experimental paradigm that mimicked the pain-related fear individuals with chronic pain may experience as a consequence of stimulus-evoked pain (e.g., allodynia; perceiving non-painful touch as painful) or as a consequence of stimulus-independent pain (e.g., spontaneous pain fluctuations). We developed a classical cued and contextual fear conditioning paradigm that employed innocuous vibrotactile stimulation of the fingers as conditioned stimuli (CSs) and painful electrocutaneous stimulation of the ipsilateral wrist as an unconditioned stimulus (US). With this paradigm and meta-analytic methods, we addressed the following research questions: 1) do participants acquire (Chapter 2), generalize (Chapter 3), and extinguish (Chapter 2) conditioned fear responses to touch when associated with pain? 2) Are the neural correlates of pain-related fear comparable to the neural correlates of other conditioned fears (using merely aversive, non-painful stimuli as USs) (Chapter 4)? 3) What are the neural networks related to fear of touch (Chapter 5)? We found that participants successfully acquired and extinguished both cued and contextual fear of touch (Chapter 2). However, we did not find evidence of fear generalization to novel touch (Chapter 3). From these results we conclude that pain-related fear responses to innocuous touch can develop and reduce in a manner consistent with contemporary associative learning theories, although the spreading of fear of touch requires further investigation. We found that the neural network relating to the acquisition of cued fear of touch included regions involved in emotional learning processes (putamen, angular gyrus, anterior insula, and ventromedial prefrontal cortex/vmPFC), motor regions (primary motor cortex/MI and supplementary motor area/SMA), and somatosensory regions (primary and secondary somatosensory cortices/SI and SII). The neural correlates of contextual fear of touch were limited to the bilateral caudate nuclei (Chapter 5). These results, combined with our finding that the primary somatosensory cortex (SI) is differentially recruited for pain-related fear compared to other conditioned fears (Chapter 4), points to a crucial role for somatosensory processing in the experience of pain-related fear. In Chapter 6, we discuss the potential implications of these findings, and directions for future research that could build on this work status: published

Tinnitus (i.e. ringing in the ear) can become a disability for some. For these individuals, fear of tinnitus appears to be at the heart of the condition. This work focused on better understanding the role fear plays. First, the study set out to create fear of neutral sounds based solely on their intensity (i.e. volume) – given that tinnitus is commonly reported after exposure to loud environments (e.g. bars, parties, festivals). No study has ever attempted to create such a paradigm with human participants before. Furthermore, the research explored innovative methodology delivered through an app (Ecological Momentary Assessment). The app increases the accuracy of symptom assessment by asking patients about their experiences through the day. Contrary to some common beliefs, constantly asking participants about their tinnitus did not worsen their condition. The last study compared group to individual therapy. Using an innovative design, focused on a handful of participants’ individual experiences, group therapy proved more beneficial.

Why is it that some people develop chronic pain after an injury, while others do not? Pain has a clear function for our survival, because it signals potential harm or danger to the body and promotes behaviours, such as avoidance and escape, to protect ourselves against these dangers. However, pain could also become a false alarm, especially in the case of chronic pain, where there is often no objectifiable injury and where pain is disconnected from its original function. This PhD research project introduced a new line of experimental work to further investigate the relationship between pain-related avoidance behaviour and pain-related fear. In a series of studies (the perception of) avoidance behaviour was experimentally manipulated and its effects on changes in fear and pain reports were tested. The results of these studies indicated that engaging in avoidance may (paradoxically) increase rather than decrease pain-related fear (i.e. bidirectionality hypothesis, whereby pain-related fear leads to avoidance behaviour (one direction) and in turn, engaging in avoidance behaviour increases pain-related fear (other direction)).

Concerns about falls is a common problem among elderly people living independently and forms a threat to their self-reliance. The group course 'Zicht op Evenwicht' (originally developed in the US under the name A Matter of Balance) has shown to improve people's concerns about falls and their daily functioning, but many elderly people do not finish the course because of health problems. In order to reach these vulnerable elderly people living independently, an individual home version was developed and evaluated in a randomised trial (N=389). The evaluation shows that the individual home course is easy to use, and more effective and cost-effective than regular care. It is therefore recommended that this programme be implemented in regular Dutch healthcare.

Despite the strong emphasis on large N designs in most statistical and methodological courses and handbooks, single-case designs are gaining popularity. They can provide a viable alternative or supplement to group studies to investigate causal research questions. This could be the case when it is unnecessary to collect data from a large group of subjects (e.g., generating pilot data) or when this is impossible (e.g., studying rare conditions). Although several data-analytic techniques have been suggested for the analysis of single-case experiments, visual analysis still remains the predominant method. An important reason is the absence of these techniques in popular statistical packages. The focus of this doctoral research project is on providing user-friendly tools for analyzing single-case data. As a statistical technique, randomization tests were selected, because they are promising for analyzing the specific data resulting from single-case experiments. For the software development, the statistical programming language R was chosen. To enhance the user-friendliness, an implementation in the window-based graphical user interface, the R commander, was also created.The developed software is presented in six separate manuscripts and contains functions for three important steps in analyzing single-case data: visual exploration, statistical significance testing, and effect size calculation. Manuscript 1 presents the SCVA package, which helps researchers in making graphical representations of single-case data and to transform graphical displays back to raw data. Manuscript 2 introduces the SCRT package for designing single-case phase and alternation experiments, as well as for conducting randomization tests on data resulting from these experiments. In manuscript 3, a systematic review on the use of multiple baseline designs is provided. Since it was found that most multiple baseline studies in the sample data relied solely on visual analysis of the data, in manuscript 4 an extension of the SCRT package is presented for use with multiple baseline data. Manuscript 5 explains the use of the SCMA package, with functions for probability combining and effect size calculation. In manuscript 6, all functionalities are combined in the RcmdrPlugin.SCDA package: a window-based graphical user interface, which overcomes the difficulties of the command line interface of R.By making these data-analytic tools available and assemble them in one overarching user-friendly system, we wish to contribute to their familiarity with applied researchers, and hence their increased use in empirical studies. The scripts could also be used in stochastic simulation studies, and in this way add to the knowledge on the statistical properties of effect size measures and statistical techniques for single-case data. status: published

Patients with chronic pain are not only confronted with the pain and its influence on their doings, but also with its influence on their ‘being’. Kindermans studied the role of self-discrepancies in chronic pain. Self-discrepancies are differences people experience between who they are and who they would ideally want to be (ideal self), who they think they should be (imposed self), and who they fear to be (feared self). These discrepancies can lead to depression or anxiety complaints. It turned out that the greater discrepancies patients with chronic pain experienced between their true self and the other self-images, the more they suffered from depression and anxiety complaints. Patients who could more flexibly deal with their objectives experienced fewer negative emotions in spite of present self-discrepancies. The closer patients felt to their feared self, the more they reported avoidance, which resulted in more limitations and a reduced quality of life.

In chronic pain patients, pain related fear considerably contributes to the maintenance of the experienced functional limitations. Pain related fear is fear of moving and/or fear of (renewed) injury, or fear of pain or other types of physical sensations, or fear of the future (for example of becoming restrained to a wheelchair, not being able to work anymore, or no longer being the person you always wanted to be). An exposure in vivo treatment (GEXP), in which patients are exposed step by step to the situations, activities or movements they are afraid of appears to be an effective treatment. Patients experience in various situations, both short and long term, fewer functional limitations and even less pain, and changes on the tissue level. Where traditional pain treatments often do not lead to the desired result, GEXP appears the appropriate treatment.

Although the modified Stroop paradigm is considered to be a prominent paradigm for investigating selective attention in emotional disorders, relatively few studies have applied this paradigm to examine selective attention in chronic pain patients. Moreover, the results from these studies are not robust. The purpose of this article is to review the evidence for attentional bias in chronic pain patients, by means of a meta-analysis. Data from five studies were pooled and summarized into a mean difference (MD). Significant MD estimations (in milliseconds) were found for both sensory pain words (MD = 26.7; 95% CI 10.0-42.9) and affective pain words (MD = 28.1; 95% CI 0.4-55.8). Meta regression analysis indicated that methodological quality did not significantly affect the pooled MD estimation for both sensory pain words and affective pain words. Thus, the results from the present meta-analysis on studies applying the modified Stroop paradigm, suggest that chronic pain patients selectively attend to both pain sensory and pain affective stimuli. Furthermore, the MD estimation did not depend upon the methodological quality tentatively indicating that even though studies differed in methodology, the results were rather consistent. Implications of the results are discussed. * Roelofs, J., Peters, M. L., Zeegers, M. P. A., Vlaeyen, J. W. S. (2002). The modified Stroop paradigm as a measure of selective attention towards pain-related stimuli among chronic pain patients: a metaanalysis. European Journal of Pain, 6, 273-281. 24 CHAPTER 2 – PAIN-RELATED FEAR AND SELECTIVE ATTENTIONAL PROCESSING