Pain 107 (2004) 70–76
www.elsevier.com/locate/pain
Disengagement from pain: the role of catastrophic thinking about pain
Stefaan Van Dammea,c,*, Geert Crombeza,c, Christopher Ecclestonb
a
Department of Experimental-Clinical and Health Psychology, Faculty of Psychology and Educational Sciences,
Ghent University, Henri Dunantlaan 2, 9000 Ghent, Belgium
b
Department of Psychology, University of Bath, Bath, UK
c
Research Institute for Psychology and Health, Utrecht, The Netherlands
Received 15 July 2003; received in revised form 17 September 2003; accepted 25 September 2003
Abstract
This paper reports an experimental investigation of attentional engagement to and disengagement from pain. Thirty-seven pain-free
volunteers performed a cueing task in which they were instructed to respond to visual target stimuli, i.e. the words ‘pain’ and ‘tone’. Targets
were preceded by pain stimuli or tone stimuli as cues. Participants were characterized as high or low pain catastrophizers, using self-reports.
We found that the effect of cueing upon target detection was differential for high and low pain catastrophizers. Analyses revealed a similar
amount of attentional engagement to pain in both groups. However, we also found that participants high in pain catastrophizing had difficulty
disengaging from pain, whereas participants low in pain catastrophizing showed no retarded disengagement from pain. Our results provide
further evidence that catastrophic thinking enhances the attentional demand of pain, particularly resulting in difficulty disengaging from pain.
The clinical implications of these findings are discussed.
q 2003 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
Keywords: Attention; Experimental pain; Catastrophizing
1. Introduction
The function of pain to demand attention, interrupt
current activity, and generally interfere with a range of
cognitive processes, is now well documented in both
clinical and non-clinical populations (Eccleston and
Crombez, 1999; Pincus and Morley, 2001). The selection
of pain over other potential targets of attention is a normal,
adaptive process, because pain is associated with danger and
the urge to prioritize escape from potential bodily harm.
The attentional demand of pain has been studied
principally by the exploitation of a primary task paradigm,
in which participants are instructed to ignore pain while
performing an attention-demanding task. Within this
paradigm, the degradation of task performance in the
context of pain is used as a measure of attentional disruption
by pain (Crombez et al., 1994; Eccleston, 1994). Catastrophic thinking about pain, defined as an exaggerated
* Corresponding author. Address: Department of Experimental-Clinical
and Health Psychology, Faculty of Psychology and Educational Sciences,
Ghent University, Henri Dunantlaan 2, 9000 Ghent, Belgium. Tel.: þ 32-92649105; fax: þ32-9-2649149.
E-mail address: [email protected] (S. Van Damme).
negative orientation toward the threat of actual or
anticipated pain (Sullivan et al., 2001), has been found to
enhance attentional disruption by pain in both clinical and
non-clinical populations (Crombez et al., 1998a, 2002a).
The primary task paradigm was an advance over the
more traditional distraction paradigm that dominated
attempts to examine attention and pain (Eccleston, 1995).
However, its utility is limited to gross measurement of
attentional disruption. The specific processes involved in
this disruption are not afforded scrutiny. Three components
of attention to all forms of threat have been distinguished
(Van Damme et al., 2004, in press): (1) shift toward threat,
(2) engagement to threat, and (3) disengagement from
threat. Van Damme et al. (2002b) investigated engagement
to and disengagement from signals of impending pain, using
a cueing paradigm. They instructed participants to detect
pain stimuli and tone stimuli, preceded by visual signals
informing them of the sensory modality of the stimuli.
Attention to one modality facilitates the detection of stimuli
presented in that modality (engagement), and inhibits the
detection of stimuli presented in the other modality
(disengagement). Analyses revealed a similar amount of
engagement to pain signals and to tone signals. However,
0304-3959/$20.00 q 2003 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.pain.2003.09.023
S. Van Damme et al. / Pain 107 (2004) 70–76
71
Thirty-seven undergraduate psychology students (six
males and 31 females; mean age ¼ 19.35 years; SD ¼ 3.10;
range 17– 33 years) participated to fulfil course requirements. All participants gave informed consent and were free
to terminate the experiment anytime.
characters (8 mm high, 5 mm wide) against the black
background of an SVGA computer monitor for a duration of
200 ms. The presentation of cue and target stimuli was
controlled by a TURBO PASCAL 5.0 program operating in
SVGA graphics mode on an IBM compatible 386 computer.
Participants were individually tested in a sound-attenuated room designed for psychophysiological experiments.
The cueing task required participants to respond with the
dominant hand to pain (tone) targets by pressing the left
(right) button of a two-button console. Each trial began with
a fixation cross (500 ms) in the middle of the screen. The
fixation cross was followed at offset by a cue. The target was
presented at stimulus onset asynchronies (SOA) of 100, 200,
500, or 700 ms (SOA: time interval between cue onset and
target onset). In most trials, a cue and a target were
presented (cue £ target trials). There was no contingency
between cues and targets: in half of the cue £ target trials,
the cue was followed by the corresponding target (validly
cued trials), whereas in the other half, the cue was followed
by the non-corresponding target (invalidly cued trials). In a
number of trials, the target was not preceded by a cue
(uncued trials). In order to control for cue responding, there
was a number of trials in which only a cue and no target was
presented (cue only trials). Finally, in order to ensure that
participants attended to the screen, a randomly selected digit
between one and nine was presented on some trials instead
of a cue or a target (digit trials). Participants were asked to
report the digit aloud. A trial ended when a participant
responded or 2000 ms had elapsed. The inter-trial interval
varied among 1500, 2000, and 2500 ms. Experimental
duration was approximately 30 min.
2.2. Apparatus and cueing task
2.3. Procedure
Cues consisted of pain stimuli and tone stimuli. Pain
stimuli were transcutaneous electrocutaneous stimuli,
delivered by an AC stimulator with an internal frequency
of 50 Hz, an instantaneous rise and fall time, and a duration
of 300 ms. The stimuli were delivered by two Fukuda
standard Ag/AgCl electrodes (1 cm diameter) filled with a
lubricant. The electrodes were attached to the non-dominant
forearm. The skin at the electrode sites was first abraded
with a peeling cream to reduce skin resistance. Intensity of
the pain stimulus was 0.63 mA. Using the sensory pain
words of the Dutch McGill Pain Questionnaire (Vanderiet
et al., 1987), it was found that the characteristics of this
stimulus were best described as pricking, boring, flickering,
electric and cutting (Crombez et al., 1998a). Previous
studies have further demonstrated that an electrocutaneous
stimulus of this intensity is painful but easy to tolerate, and
that the attentional demand of this stimulus is strongly
related to the specific threat value of pain (Crombez et al.,
1998a). The tone stimulus was a 500 Hz pitched tone
(duration of 300 ms) produced by the computer.
Target stimuli were the Dutch words for pain (‘pijn’) and
for tone (‘toon’). Targets were presented in white uppercase
2.3.1. Preparation phase
Participants were informed that the electrocutaneous
stimulus ‘stimulates the pain fibres and that most people find
this kind of stimulation unpleasant’. To familiarise
participants with the pain stimulus, they were given a series
of electrocutaneous stimuli with increasing intensity (0.032,
0.16, 0.32, and 0.63 mA).
participants experienced pronounced difficulty disengaging
attention from pain signals, but not from tone signals. This
difficulty disengaging from signals of impending pain was
particularly strong in participants high in catastrophic
thinking about pain.
Because this paradigm only allows an investigation of
attention to signals of pain, we developed a modification in
order to investigate attention to pain itself. We instructed
participants to detect the words ‘pain’ and ‘tone’, which
were preceded by a pain stimulus or a tone stimulus, serving
as attentional cues, or no stimulus. There was an equal
number of validly and invalidly cued targets. Engagement
was operationalized as the response time benefit of a valid
cue compared to no cue. Disengagement was identified as
the response time cost of an invalid cue compared to no cue.
In line with Van Damme et al. (2002b), we expected to find
strong engagement to and retarded disengagement from
pain, and we further hypothesized that difficulty disengaging from pain would be particularly pronounced in
pain catastrophizers.
2. Method
2.1. Participants
2.3.2. Practice phase
Participants were instructed to respond to the targets as
quickly as possible without sacrificing accuracy. Participants were informed about cues and targets, and they were
instructed to respond only to targets. They were informed
that on some trials only a digit would appear which they had
to report aloud. The practice phase consisted of nine trials:
two validly cued trials, two invalidly cued trials, two uncued
trials, two cue only trials, and one digit trial. The order of
trial presentation was randomized.
2.3.3. Experiment phase
The experiment phase consisted of 108 trials: 24 validly
cued trials, 24 invalidly cued trials, 24 uncued trials, 24 cue
72
S. Van Damme et al. / Pain 107 (2004) 70–76
only trials, and 12 digit trials. The order of presentation was
randomized with the restriction that no more than two
consecutive trials were of the same trial type. SOA levels
(100, 200, 500, or 700 ms) were equally distributed across
trial type.
2.3.4. Post-experiment phase
After the experiment phase was finished, participants
completed a number of questionnaires. As a manipulation
check, the valence and arousal of the cues and the targets
were assessed using a 9-point numerical graphic rating scale
(Lang, 1980). For valence, the scale ranged from a smiling
figure (minimum score ¼ 0) to an unhappy figure (maximum score ¼ 9). For arousal, the scale ranged from a sleepy
figure with eyes closed (minimum score ¼ 0) to an excited
figure with eyes open (maximum score ¼ 9). Furthermore,
the predictive value of the cues was assessed. Using an
11-point numerical graphic rating scale (anchored 0 ¼ not
at all and 10 ¼ very strong), participants reported to what
extent they expected each target after the presentation of
each cue. Finally, participants completed the Dutch version
of the Pain Catastrophizing Scale (PCS; Crombez et al.,
1998a; Sullivan et al., 1995). The PCS is a 13-item scale for
both non-clinical and clinical populations. Participants are
asked to reflect on past painful experiences and to indicate
the degree to which they experienced each of the 13 thoughts
or feelings during pain (e.g. ‘I become afraid that the pain
may get worse’) on a 5-point scale from 0 (not at all) to 4 (all
the time). The Dutch version of the PCS has been shown to
be valid and reliable (Van Damme et al., 2002a).
2.4. Statistical analyses
A 2 (pain catastrophizing: low, high) £ 2 (cue: valid, no,
invalid) £ 2 (target: tone, pain) £ 4 (SOA: 100, 200, 500,
700 ms) ANOVA with repeated measures was performed
upon the mean RTs of each trial type. Because we were
interested in comparing attentional processes between high
pain catastrophizers and low pain catastrophizers, pain
catastrophizing was included as a between-subject variable.
We used the median of the PCS ðMed ¼ 19; M ¼ 18:95;
SD ¼ 6:50Þ to differentiate between a group of high pain
catastrophizers (n ¼ 20; M ¼ 23:90; SD ¼ 3:68; range
19 – 33) and a group of low pain catastrophizers
(n ¼ 17; M ¼ 13:12; SD ¼ 3:48; range 4– 18). Available
norms show that high pain catastrophizers in our sample are
representative for the population of undergraduates
(Van Damme et al., 2000). Greenhouse-Geisser corrections
(with corrected degrees of freedom) are presented when the
sphericity assumption was violated (Mauchly’s Test of
Sphericity; P , 0:05). As an estimate of effect size,
percentage of variance (PV) was reported for the hypothesized effects. Following Cohen’s guidelines (Cohen, 1988),
effect sizes of 0.01, 0.10. and 0.25 were used as thresholds to
define small, medium and large effects, respectively.
3. Results
3.1. Self-report data
Pain cues were more threatening than tone cues. Participants
rated pain stimuli ðM ¼ 6:19; SD ¼ 1:41Þ as more negative
than tone stimuli ðM ¼ 4:11; SD ¼ 1:94Þ ðFð1; 36Þ ¼
20:26; P , 0:001Þ; and they rated pain stimuli ðM ¼ 6:03;
SD ¼ 2:32Þ as more arousing than tone stimuli ðM ¼ 4:86;
SD ¼ 2:12Þ; ðFð1; 36Þ ¼ 6:25; P , 0:05Þ: Similar effects
were found for the targets. Participants rated the pain
word ðM ¼ 4:68; SD ¼ 1:45Þ as more negative than the
tone word ðM ¼ 3:51; SD ¼ 1:54Þ; ðFð1; 36Þ ¼ 17:81; P ,
0:001Þ; and they rated the pain word ðM ¼ 4:95; SD ¼ 2:16Þ
as more arousing than the tone word ðM ¼ 4:11; SD ¼
2:20Þ; ðFð1; 36Þ ¼ 5:71; P , 0:05Þ:
There were no significant differences between high and
low pain catastrophizers in their valence ratings of pain
stimuli ðFð1; 36Þ ¼ 1:51; nsÞ and tone stimuli ðFð1; 36Þ ¼
0:98; nsÞ: Furthermore, high and low pain catastrophizers
did not differ in their arousal ratings of pain stimuli
ðFð1; 36Þ ¼ 2:30; nsÞ and tone stimuli ðFð1; 36Þ ¼ 2:54;
nsÞ: Similarly, there were no significant differences
between high and low pain catastrophizers in their
valence ratings of the pain word ðFð1; 36Þ ¼ 0:12; nsÞ
and the tone word ðFð1; 36Þ ¼ 0:07; nsÞ: Finally, high and
low pain catastrophizers did not differ in their arousal
ratings of the pain word ðFð1; 36Þ ¼ 0:38; nsÞ and the tone
word ðFð1; 36Þ ¼ 0:02; nsÞ:
Although there was no contingency between cue type
and target type, participants believed that cues predicted
targets. After the presentation of the pain stimulus,
participants reported a significantly higher expectation of
the pain word ðM ¼ 4:93; SD ¼ 2:33Þ compared to the
tone word ðM ¼ 3:45; SD ¼ 2:09Þ; Fð1; 36Þ ¼ 11:90; P ¼
0:001: Similarly, after the tone stimulus, participants
reported a significantly higher expectation of the tone
word ðM ¼ 5:03; SD ¼ 2:22Þ compared to the pain word
ðM ¼ 3:89; SD ¼ 2:21Þ; Fð1; 36Þ ¼ 6:86; P , 0:05: Participants had no stronger belief in the predictive value of the
pain stimulus as a cue ðM ¼ 1:49; SD ¼ 2:62Þ than in the
predictive value of the tone stimulus as a cue ðM ¼ 1:14;
SD ¼ 2:64Þ: Participants’ belief in the predictive value of
the pain stimulus as a cue was calculated as the expectancy
that the pain stimulus would be followed by the pain word
minus the expectancy that the pain stimulus would be
followed by the tone word. Similarly, participants’ belief in
the predictive value of the tone stimulus as a cue was
calculated as the expectancy that the tone stimulus would be
followed by the tone word minus the expectancy that the
tone stimulus would be followed by the pain word.
High pain catastrophizers had a significantly stronger
belief in the predictive value of the pain stimulus as a cue
compared to low pain catastrophizers, Fð1; 36Þ ¼ 6:03; P ¼
0:019: However, high pain catastrophizers had no stronger
S. Van Damme et al. / Pain 107 (2004) 70–76
73
belief than low pain catastrophizers in the predictive value
of the tone stimulus as a cue, Fð1; 36Þ ¼ 1:52; ns:
3.2. Response time data
Trials with errors ð, 2%Þ and outliers (response times
(RT) less than 150 ms and greater than 1500 ms) ð, 1%Þ
were omitted from RT analyses. A 2 (pain catastrophizing:
low, high) £ 2 (cue: valid, no, invalid) £ 2 (target: tone,
pain) £ 4 (SOA: 100, 200, 500, 700 ms) ANOVA with
repeated measures was performed upon the mean RTs of
each trial type. Pain catastrophizing was included as a
between-subject variable.
We found a significant main effect of cue, Fð1:64;
57:48Þ ¼ 7:85; MSE ¼ 2969:49; P , 0:01:
Responses
were faster when words were preceded by valid cues
ðM ¼ 478 msÞ compared to no cues ðM ¼ 490 msÞ or
invalid cues ðM ¼ 494 msÞ: Also the main effect of target
was significant, Fð1; 35Þ ¼ 5:09; MSE ¼ 3965:00; P ,
0:05; indicating faster responses to the pain word
ðM ¼ 483 msÞ compared to the tone word ðM ¼ 492 msÞ:
Furthermore, there was a significant main effect of
SOA, Fð3; 105Þ ¼ 7:71; MSE ¼ 3054:14; P , 0:001; indicating slower responses to trials with cue-target
overlap ðSOA100 : M ¼ 495 ms; SOA200 : M ¼ 495 ms;
SOA500 : M ¼ 473 ms; SOA700 : M ¼ 487 msÞ: As our
hypotheses relate to the effects of cues upon target
detection, we were particularly interested in the interactions
containing cue and target factors. The Cue £ Target
interaction effect was not significant ðF , 1Þ: However,
we found a significant Pain catastrophizing £ Cue £ Target
interaction effect, Fð2; 70Þ ¼ 4:30; MSE ¼ 3948:79;
P , 0:05: All other interactions were not significant
(all Fs , 1:50).
Of particular interest to this study was the significant
Pain catastrophizing £ Cue £ Target interaction, indicating
a differential effect of cues upon target detection, dependent
upon the level of pain catastrophizing. Therefore we
analyzed this effect separately for high and low pain
catastrophizers in terms of RT benefits of valid cues and RT
costs of invalid cues. For each type of target, we tested
whether a valid cue in comparison with no cue facilitated
the detection of the target. Significant benefits of a valid cue
reflect attentional engagement to the cue. Furthermore, we
tested for each type of target whether an invalid cue in
comparison with no cue impaired the detection of the target.
Significant costs of an invalid cue reflect difficulty
disengaging from the cue. Analyses were performed using
a priori one-tailed t-tests for dependent samples. All effects
are illustrated in Fig. 1.
3.2.1. High pain catastrophizers
We found significant benefits of the tone stimulus as a
valid cue, tð19Þ ¼ 2:69; P ¼ 0:007; but not of the pain
stimulus as a valid cue, tð19Þ ¼ 1:55; P ¼ 0:070; reflecting
strong attentional engagement to the tone stimulus as a cue
Fig. 1. Mean response times as a function of cue stimulus (tone cue
stimulus, no cue stimulus, pain cue stimulus) and target (tone word, pain
word) in high and low pain catastrophizers. Small bars indicates the
standard error of the mean.
to detect the tone word, but not to pain stimulus as a cue to
detect the pain word. Furthermore, we found significant
costs of the pain stimulus as an invalid cue, tð19Þ ¼ 1:87;
P ¼ 0:039; but not of the tone stimulus as an invalid cue,
tð19Þ ¼ 0:52; ns, reflecting retarded disengagement from the
pain stimulus to detect the tone word, but not from the tone
stimulus to detect the pain word.
3.2.2. Low pain catastrophizers
There were no significant benefits of the tone stimulus as
a valid cue, tð16Þ ¼ 0:17; ns, and the pain stimulus as a valid
cue, tð16Þ ¼ 1:04; ns, showing that there was no strong
attentional engagement to the pain stimulus to detect the
pain word, and to the tone stimulus to detect the tone word.
Furthermore, we found significant costs of the tone stimulus
as an invalid cue, tð16Þ ¼ 2:83; P ¼ 0:006; but not of the
pain stimulus as an invalid cue, tð16Þ ¼ 0:81; ns. Participants had pronounced difficulty disengaging from the tone
stimulus to detect the pain word, but not from the pain
stimulus to detect the tone word.
3.2.3. Test between high and low pain catastrophizers
Differences between high and low pain catastrophizers
were further analyzed using a priori one-tailed t-tests. We
tested whether engagement to pain was stronger in high pain
catastrophizers than in low pain catastrophizers. The pain
stimulus did not facilitate the detection of the pain word
more in high pain catastrophizers compared to low pain
catastrophizers, tð35Þ ¼ 0:21; ns ðPV ¼ 0:00Þ: Furthermore, we tested the hypothesis that disengagement from
pain would be more retarded in high versus low pain
74
S. Van Damme et al. / Pain 107 (2004) 70–76
catastrophizers. This hypothesis was supported, tð35Þ ¼
1:86; P ¼ 0:036; with a medium effect size ðPV ¼ 0:10Þ:
As expected, high pain catastrophizers had a pronounced
difficulty disengaging attention from the pain stimulus to
detect the tone word. In contrast, low pain catastrophizers
had no difficulty disengaging attention from the pain
stimulus to detect the tone word. An interesting yet
unexpected finding was that high pain catastrophizers had
less difficulty than low pain catastrophizers disengaging
attention from the tone stimulus to detect the pain word,
tð35Þ ¼ 1:84; P ¼ 0:037 ðPV ¼ 0:09Þ: This indicates that
high pain catastrophizers were less retarded in disengaging
attention from neutral information in order to detect painrelated information, suggesting a rapid shift to pain
information in individuals for whom pain has a high threat
value. All effects are presented in Fig. 1.
3.2.4. Effects of expectancies on attentional components
Participants’ belief in the predictive value of the pain
stimulus as a cue was not significantly correlated with
attentional engagement to the pain stimulus ðr ¼ 0:06; nsÞ;
and disengagement from the pain stimulus ðr ¼ 0:22; nsÞ:
Participants’ belief in the predictive value of the tone stimulus
as a cue tended to be negatively correlated with attentional
engagement to the tone stimulus ðr ¼ 20:29; P ¼ 0:086Þ; and
was not significantly correlated to disengagement from the
tone stimulus ðr ¼ 0:01; nsÞ:
4. Discussion
The main objective of this study was to investigate
attentional engagement to and disengagement from pain.
Furthermore, we wanted to examine whether these processes were affected by the level of catastrophic thinking
about pain. We found a similar amount of attentional
engagement to pain in participants high and low in pain
catastrophizing. However, as expected, high pain catastrophizers had pronounced difficulty disengaging from pain,
compared to low pain catastrophizers. This effect was not
short-lived, as it was found across all SOA levels. These
results extend the findings of Crombez et al. (1998a), who
demonstrated that pain-free volunteers with a high
frequency of catastrophic thinking about pain, had pronounced task interference when pain was administered.
However, Crombez et al. (1998a) used a primary-task
paradigm, as a result of which it was not possible to identify
which attentional component caused task disruption. Our
findings suggest that it is in particular the inability to
disengage attention from pain and shift it to other task
demands that is affected by catastrophic thinking about pain.
This is in line with the study of Van Damme et al. (2002b),
who found that pain catastrophizing was related to retarded
disengagement from but not to engagement to signals of
impending pain.
It is possible that expectancies have played a role in the
retarded disengagement from pain in pain catastrophizers.
Indeed, self-reports indicated that high pain catastrophizers
had a stronger belief than low pain catastrophizers in the
predictive value of the pain stimulus as a cue. However,
participants’ belief in the predictive value of the pain
stimulus as a cue was not significantly correlated with
disengagement from the pain stimulus. This suggests that
expectancies did not mediate between catastrophic thinking
about pain and difficulty disengaging from pain in our
sample. This is in contrast with the study of Van Damme
et al. (2002b), who found that the relation between
catastrophic thinking about pain and retarded disengagement from signals of impending pain was mediated by
participants’ expectancies that the pain signal would be
followed by pain.
An alternative explanation for these effects may be that
the threatening context of the experiment, i.e. the use of pain
stimuli, activated ‘pain schemata’, representing the sensory,
spatial, temporal, and affective properties of the pain
experience (Pincus and Morley, 2001). Activation of pain
schemata may elicit a negative state, increasing the
accessibility of schema-congruent information, and interfering with the processing of schema-incongruent information (Bower et al., 1981). For example, in a study of
Seltzer and Yarczower (1991), it was found that exposure to
aversive stimulation increased the retrieval of negative
words, and decreased the encoding of positive words,
regardless of whether they were accompanied by a pain
stimulus. Pain schemata may be activated more swiftly and
may contain more excessively negative and pessimistic
information in pain catastrophizers (Sullivan et al., 2001).
The activation of pain schemata, favouring the selection of
pain-related information over pain-irrelevant information
may explain why pain catastrophizers had pronounced
difficulty disengaging from the pain stimulus in order to
detect the tone word. Furthermore, schemata activation by
the threatening context of the experiment may also account
for the finding that high pain catastrophizers had less
difficulty disengaging from the tone in order to detect the
pain word compared to low pain catastrophizers.
The results of this study corroborate the idea that retarded
disengagement is a prominent component of attention to
pain in high pain catastrophizers. Our findings may have
clinical relevance. It is suggested that attention is not
engaged more strongly to pain than to stimuli in other
sensory modalities, such as vision and audition. Furthermore, attentional engagement to pain appears to be
independent from the level of catastrophic thinking about
pain. In contrast, only participants high in catastrophic
thinking about pain showed difficulty disengaging from
pain. Applied to the situation of the chronic pain patient, a
sustained difficulty disengaging attention from pain sensations and shifting to other demands in the environment,
may be an important factor in maintaining pain and
disability. Indeed, the inability to disengage from attentional
S. Van Damme et al. / Pain 107 (2004) 70–76
disruption by pain may result in a clinical pattern of
heightened pain experience (Crombez et al., 2004; in press
McDermid et al., 1996), avoidance behaviour (Asmundson
et al., 1997; Crombez et al., 1998b), worry (Aldrich et al.,
2000), and emotional distress (McCracken, 1997). Therefore, in clinical practice, traditional attentional distraction
strategies may not be effective in high pain catastrophizers.
It may be more useful to reduce the threat value of pain,
using exposure techniques that disconfirm the belief of
catastrophic outcomes (Crombez et al., 2002b; Goubert
et al., 2002; Vlaeyen et al., 2002). In addition, a useful
alternative to distraction may be ‘attentional regulation’
(Elliot and Eccleston, 2003). Because interruption by pain is
an inescapable fact of life, dynamic switching between pain
and other demands is necessary to cope with pain (Eccleston
and Crombez, 1999). Attentional regulation implies that
chronic pain patients learn to regulate their attention to pain
by re-engaging with positive, changeable, and controllable
aspects of themselves and their environment (Elliot and
Eccleston, 2003).
There is a number of issues that need further consideration. First, we found no facilitated engagement to pain in
both high and low pain catastrophizers. One possible
explanation is that the use of pain stimuli as cues may
have resulted in a general interference, reducing the RT
benefits of pain stimuli as valid cues. This is in line with
studies investigating the effects of pain on the encoding of
information. For example, Kuhajda et al. (2002) found in a
sample of chronic headache patients that participants who
had pain during the encoding of affective words, were
significantly slower judging the words as positive or
negative. Second, we found that high but not low pain
catastrophizers had a strong attentional engagement to the
tone. A possible explanation of this finding is that the tone,
because of its safety value, is more relevant to high pain
catastrophizers compared to low pain catastrophizers. This
greater relevance of the tone may have allowed high pain
catastrophizers to direct attention more easily to the
corresponding tone target. Third, the finding that low pain
catastrophizers showed difficulty disengaging from the tone
stimulus to detect the pain word, but no difficulty
disengaging from the pain stimulus to detect the tone
word, might be explained by inhibited processing of painrelated stimuli. As these stimuli are perceived as only mildly
threatening by low pain catastrophizers, this explanation is
in line with Mogg and Bradley (1998), who argued that the
attentional system inhibits the thorough processing of
stimuli with a low threat value. Fourth, it is important to
note that this study was conducted in pain-free volunteers,
using experimental pain stimuli. Therefore, one has to be
cautious in generalizing the results to chronic pain patients
until robust evidence is found for the role of retarded
disengagement of attention from pain in clinical
populations.
In conclusion, the present study is the first to demonstrate
that pain catastrophizing affects in particular attentional
75
disengagement from pain in order to shift towards other
environmental demands. Further research is needed to
replicate these findings in other non-clinical populations and
in chronic pain patients.
Acknowledgements
This study was supported by a research grant
(G.0107.00) to Geert Crombez of the Fund for Scientific
Research, Flanders, Belgium. The authors want to thank
Evy Maes for her contribution in the data collection.
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