Our understanding of chronic pain involves complex brain circuits that include sensory, emotional, cognitive and interoceptive processing. The feed-forward interactions between physical (e.g., ...trauma) and emotional pain and the consequences of altered psychological status on the expression of pain have made the evaluation and treatment of chronic pain a challenge in the clinic. By understanding the neural circuits involved in psychological processes, a mechanistic approach to the implementation of psychology-based treatments may be better understood. In this review we evaluate some of the principle processes that may be altered as a consequence of chronic pain in the context of localized and integrated neural networks. These changes are ongoing, vary in their magnitude, and their hierarchical manifestations, and may be temporally and sequentially altered by treatments, and all contribute to an overall pain phenotype. Furthermore, we link altered psychological processes to specific evidence-based treatments to put forth a model of pain neuroscience psychology.
Adverse childhood experiences (ACEs) in youth have been found to be frequently associated with several chronic illnesses, including chronic pain. However, this relationship remains poorly understood. ...Previous research has examined the association between ACEs and chronic pain, but these have primarily been examined in the context of adults with limited assessment of ACEs and individual pain conditions. The primary objectives of this study were to examine the incidence and psychological/pain-related correlates of ACEs in a sample of youth with chronic pain. Exploratory analyses were also examined using primary pain diagnosis and number of pain locations.
Data were gathered using retrospective data from a clinical databank. Participants were 141 youth aged 9 to 19 with chronic pain who presented for evaluation at a multidisciplinary pain clinic. Information on ACEs exposure, pain diagnostic information, pain-related impairment, and psychosocial functioning were gathered via self-report and retrospective review of the medical record.
Results revealed that over 80% of youth with chronic pain reported at least 1 ACE in their lifetime. Further, multiple and univariate analyses of variance revealed that ACEs exposure is significantly associated with greater symptoms of anxiety, depression, and fear of pain, with ≥3 ACEs associated with greatest impairment in functioning. No relationships were found between ACEs and increased pain-related disability or pain intensity.
ACEs exposure in youth with chronic pain occurs frequently and can be associated with increased psychosocial but not functional impairment. Future research is needed to further examine the relationship between ACEs and chronic pain in youth in a prospective manner.
A significant proportion of children and adolescents with chronic pain endorse elevated pain-related fear. Pain-related fear is associated with high levels of disability, depressive symptoms, and ...school impairment. Because of faulty nerve signaling, individuals with neuropathic pain and complex regional pain syndrome may be more prone to develop pain-related fear as they avoid use of and neglect the affected body area(s), resulting in exacerbated symptoms, muscle atrophy, maintenance of pain signaling, and ongoing pain-related disability. Not surprisingly, effective treatments for elevated pain-related fears involve exposure to previously avoided activities to downregulate incorrect pain signaling. In the context of intensive interdisciplinary pain treatment of youth with neuropathic pain, decreasing pain-related fear is associated with improved physical and psychological functioning, whereas high initial pain-related fear is a risk factor for less treatment responsiveness. An innovative approach to targeting pain-related fear and evidence of a neural response to treatment involving decoupling of the amygdala with key fear circuits in youth with complex regional pain syndrome suggest breakthroughs in our ability to ameliorate these issues.
Resilience factors have been suggested as key mechanisms in the relation between symptoms and disability among individuals with chronic pain. However, there is a need to better operationalize ...resilience and to empirically evaluate its role and function. The present study examined psychological flexibility as a resilience factor in relation to symptoms and functioning among 252 adults with chronic pain applying for participation in a digital ACT-based self-help treatment. Participants completed measures of symptoms (pain intensity, and anxiety), functioning (pain interference and depression), as well as the hypothesized resilience factor psychological flexibility (measured as avoidance, value obstruction, and value progress). As expected, symptoms, functioning and resilience factors were significantly associated. Hierarchical linear regression analyses showed that psychological flexibility significantly contributed to the prediction of pain interference and depression when adjusting for age, pain and anxiety. Also, participants with low levels of psychological flexibility were more likely to be on sick leave. Furthermore, a series of multiple mediation analyses showed that psychological flexibility had a significant indirect effect on the relationship between symptoms and functioning. Avoidance was consistently shown to contribute to the indirect effect. Results support previous findings and suggest the importance of psychological flexibility as a resilience factor among individuals with chronic pain and anxiety.
To apply resilience theory and the extant literature to propose a resilience-risk model for pediatric chronic pain and provide an agenda for research and clinical practice in pediatric chronic pain ...resilience.
Literature review to develop a resilience-risk model for pediatric chronic pain.
The chronic pain literature has identified unique individual and social/environmental resilience resources and pain-related resilience mechanisms that promote pain adaptation. These data support our ecological resilience-risk model for pediatric chronic pain, and the model highlights novel directions for clinical and research efforts for youth with chronic pain.
The examination of pediatric chronic pain from a strengths-based approach might lead to novel clinical avenues to empower youth to positively adapt and live beyond their pain.
Pediatric debilitating chronic pain is a severe health problem, often requiring complex interventions such as intensive interdisciplinary pain treatment (IIPT). Research is lacking regarding the ...effectiveness of IIPT for children. The objective was to systematically review studies evaluating the effects of IIPT.
Cochrane, Medline/Ovid, PsycInfo/OVID, PubMed, PubPsych, and Web of Science were searched. Studies were included if (1) treatment was coordinated by ≥3 health professionals, (2) treatment occurred within an inpatient/day hospital setting, (3) patients were <22 years, (4) patients experienced debilitating chronic pain, (5) the study was published in English, and (6) the study had ≥10 participants at posttreatment. The child's pain condition, characteristics of the IIPT, and 5 outcome domains (pain intensity, disability, school functioning, anxiety, depressive symptoms) were extracted at baseline, posttreatment, and follow-up.
One randomized controlled trial and 9 nonrandomized treatment studies were identified and a meta-analysis was conducted separately on pain intensity, disability, and depressive symptoms revealing positive treatment effects. At posttreatment, there were large improvements for disability, and small to moderate improvements for pain intensity and depressive symptoms. The positive effects were maintained at short-term follow-up. Findings demonstrated extreme heterogeneity.
Effects in nonrandomized treatment studies cannot be attributed to IIPT alone. Because of substantial heterogeneity in measures for school functioning and anxiety, meta-analyses could not be computed. There is preliminary evidence for positive treatment effects of IIPT, but the small number of studies and their methodological weaknesses suggest a need for more research on IIPTs for children.
Accumulating evidence supports the concurrent association between parent distress and behavior and child functioning in the context of chronic pain, with existing longitudinal studies limited to a ...pediatric surgical context that identify parent catastrophizing as influential. In this study, we examined how parent factors assessed at a multidisciplinary pediatric pain clinic evaluation affect child psychological and functional outcomes over time. A cohort of 195 patients with chronic pain (ages 8-17 years) and their parents who presented for a multidisciplinary evaluation completed measures at baseline and at 4-month follow-up. Patients completed measures of pain catastrophizing, pain-related fear and avoidance, generalized anxiety, depressive symptoms, and functional disability. Parents completed measures of pain catastrophizing, pain-related fear and avoidance, and protective responses to child pain. Parent-reported child school functioning was also collected. Parent distress and behavior was concurrently associated with child distress and functioning at evaluation. After controlling for baseline child functioning, baseline parent avoidance and protective behavior emerged as significant predictors of child functioning at 4-month follow-up. Parent distress and behavior influence child distress and functioning over time and these findings identify key parent domains to target in the context of a child's pain treatment.
Parent behavior, specifically avoidance and protective responses, influence child distress and functioning over time. Child pain treatment interventions should include influential parent factors to ensure successful outcomes.
•Stress and pain are interleaved, interact and influence each other.•Threat learning is a major contributing factor in chronic pain.•Cortisol has a pronounced effect on learning, biasing towards ...threat information.•We argue that threat learning mediates the relation between stress and chronic pain.
Stress and pain are interleaved at multiple levels - interacting and influencing each other. Both are modulated by psychosocial factors including fears, beliefs, and goals, and are served by overlapping neural substrates. One major contributing factor in the development and maintenance of chronic pain is threat learning, with pain as an emotionally-salient threat – or stressor. Here, we argue that threat learning is a central mechanism and contributor, mediating the relationship between stress and chronic pain. We review the state of the art on (mal)adaptive learning in chronic pain, and on effects of stress and particularly cortisol on learning. We then provide a theoretical integration of how stress may affect chronic pain through its effect on threat learning. Prolonged stress, as may be experienced by patients with chronic pain, and its resulting changes in key brain networks modulating stress responses and threat learning, may further exacerbate these impairing effects on threat learning. We provide testable hypotheses and suggestions for how this integration may guide future research and clinical approaches in chronic pain.
To examine pain self-efficacy and pain acceptance in relation to functioning in pediatric patients with chronic headache.
Participants were 209 youth aged 8-17 years who presented for a ...multidisciplinary pediatric headache clinic evaluation. They completed measures of pain self-efficacy and pain acceptance and a standard battery of clinical measures including indicators of emotional functioning.
Pain self-efficacy and acceptance were associated with less disability, better school functioning, and fewer depressive symptoms. While taking into account several demographic and pain-related variables, pain self-efficacy had a greater association with less functional disability, while pain acceptance had a greater association with less depressive symptoms and better school functioning.
These findings indicate that both resilience processes can serve to positively interact with functioning and symptoms of depression. Ultimately, this study suggests that higher levels of pain self-efficacy and pain acceptance in an individual experiencing pain are associated with more positive outcomes.
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