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The Impact of Modifying Attentional Bias on Vulnerability to Pain

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The Impact of Modifying Attentional Bias on Vulnerability to Pain The impact of modifying attentional bias on vulnerability to pain Jennifer O. Bowler Thesis submitted for the degree of Doctor of Philosophy University of East Anglia School of Psychology March 2015 © This copy of the thesis has been supplied on condition that anyone who consults it is understood to recognise that its copyright rests with the author and that use of any information derived therefrom must be in accordance with current UK Copyright Law. In addition, any quotation or extract must include full attribution. ATTENTIONAL BIAS AND PAIN 2 Abstract The preferential deployment of attention to noxious versus benign information in the internal and external environment - “attentional bias” - is thought to confer vulnerability to pain. The current thesis tested this putative mechanism by modifying the bias using the visual-probe task (attentional bias modification; ABM) and examining effects of this experimental manipulation on attentional bias and critical pain outcomes. Drawing on recent evidence that the impact of pain on attentional bias varies across its temporal components, this thesis additionally tested the component stages of attentional bias implicated in pain experience by manipulating the duration for which visual-probe stimuli were presented. Study 1 confirmed that both rapid and slower attentional orienting was biased in individuals with persistent musculoskeletal pain. Results from Studies 2 and 3 indicated that acute experimentally- induced pain modified the faster bias and that participants whose fast bias was modified had reduced vulnerability to cold pressor pain, in comparison with control participants. This suggested that mechanisms of initial orienting were more active in the acute pain experience. Studies 4 and 5 revealed that concurrently retraining fast and slower bias was optimal for persistent musculoskeletal pain. Results of a systematic review and meta-analysis indicated a small overall statistical effect of ABM on pain severity. Critically, however, whereas ABM had been effective at reducing acute pain severity, this was not the case for persistent pain. Overall, these findings suggest that the faster bias influenced vulnerability to acute pain, indicating a potential therapeutic target for future research. However, retraining the earlier stage of attention alone did not influence persistent pain outcomes, where there appeared to be greater involvement of the slower bias. It was concluded that not only could attentional bias influence critical pain outcomes, but that the optimal timings may vary across temporal pain classifications. ATTENTIONAL BIAS AND PAIN 3 Table of contents Abstract .................................................................................................................................... 2 Table of contents ..................................................................................................................... 3 List of tables............................................................................................................................. 8 List of figures ........................................................................................................................... 9 Acknowledgements ............................................................................................................... 11 Chapter 1 Introduction ......................................................................................................... 12 1.1 A cognitive understanding of pain: From basic science to public health ...................... 12 1.1.1 The biopsychosocial perspective and neurocognitive models of pain ....................... 12 1.1.2 Pain classifications and epidemiology ....................................................................... 19 1.2 Attentional theories and the cognitive understanding of emotion ................................. 20 1.2.1 Overview of theories of selective attention ........................................................... 20 1.2.2 Models of emotional processing ............................................................................ 24 1.2.3 Dual-process accounts of cognitive vulnerability .................................................. 26 1.2.4 Cognitive accounts of emotion .............................................................................. 28 1.2.5 Time course of attention ........................................................................................ 31 1.3 The role of attention in experimental, acute, and chronic pain ..................................... 32 1.3.1 Cognitive affective models of attention and pain .................................................. 32 1.3.2 Cognitive factors and pain ..................................................................................... 37 1.3.3 Psychological approaches to pain management ..................................................... 43 1.4 Attentional bias in pain and its modification ................................................................ 44 1.5 Thesis aims .................................................................................................................... 49 Chapter 2 Assessing the efficacy of attentional bias modification for adult pain: A systematic review and meta-analysis .................................................................................. 51 2.1 Introduction ................................................................................................................... 51 2.2 Method .......................................................................................................................... 54 2.2.1 Search strategy ....................................................................................................... 54 2.2.2 Inclusion/exclusion criteria .................................................................................... 55 2.2.3 Risk of bias assessment .......................................................................................... 57 2.2.4 Meta-analytic approach .......................................................................................... 57 2.2.5 Assessment of study heterogeneity ........................................................................ 58 2.3 Results ........................................................................................................................... 58 2.3.1 Study characterstics and systematic review ........................................................... 58 2.3.2 Risk of bias assessment .......................................................................................... 69 ATTENTIONAL BIAS AND PAIN 4 2.3.3 Data synthesis ........................................................................................................ 69 2.4 Discussion ..................................................................................................................... 72 Chapter 3 Study 1 Pain-related attentional bias in a clinical persistent pain sample versus pain free controls: A between subjects comparison ............................................... 75 3.1 Introduction ................................................................................................................... 75 3.2 Method .......................................................................................................................... 77 3.2.1 Participants............................................................................................................. 77 3.2.2 Materials ................................................................................................................ 78 3.2.3 Procedure ............................................................................................................... 82 3.3 Results ........................................................................................................................... 83 3.3.1 Group characteristics ............................................................................................. 83 3.3.2 Statistical analysis and data reduction ................................................................... 84 3.3.3 Main outcome analyses .......................................................................................... 85 3.3.4 Correlations ............................................................................................................ 87 3.4 Discussion ..................................................................................................................... 88 Chapter 4 Studies 2 and 3 Attentional bias modification for acute experimental pain: A comparison of training earlier versus later attention on pain threshold, severity and tolerance ................................................................................................................................. 91 4.1 Introduction ................................................................................................................... 91 4.2 Study Two ..................................................................................................................... 95 4.2.1 Method ................................................................................................................... 95 4.2.1.1 Participants ..................................................................................................... 95 4.2.1.2 Materials ......................................................................................................... 95 4.2.1.3 Procedure .......................................................................................................
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