Aim of the project

We suggest that the mystery of why pain and distress co-occur and sometimes persist beyond their usefulness resulting in a chronic problem is a lack of sensitivity to changes in the environment. How we appropriately respond to pain is highly dependent on the situation in which it occurs where we might consider responses in the acute phase (new injury) with those in the chronic phase. Simply put, a lack of sensitivity to the context might result in some people continuing to respond as though the pain is still an acute warning signal even though much healing has taken place, hindering recovery and triggering distress. In fact, the co-occurrence of distress and chronic pain is common, associated with many negative outcomes, and in dire need of being better understood. An alternative to viewing distress and pain as two completely separate entities, is a transdiagnostic approach that seeks to find processes that underlie and drive both problems. Because pain and emotion share many similarities, emotion regulation is deemed a primary transdiagnostic process that serves to produce appropriate responses to cope with emotion or pain that are in tune with the ever-changing demands of the environment. To be effective, these regulatory coping responses should be closely in line with the situation and research shows that rigid responses that disregard such information (are insensitive to the context) lead to psychopathology. Consequently, a lack of context sensitive responding may drive both the pain and the distress in the development of a chronic pain problem.

The aim of this project was to investigate the role of context sensitivity as a transdiagnostic factor in pain and its associated distress. We aimed to do this by conducting laboratory research to capture and measure context sensitivity in patients suffering pain, to study its role in maintaining pain, as well as to develop and test treatment methods to enhance context sensitivity and thereby improve outcomes.

Realization

We conducted a series of studies to realize the objectives of this project. We first developed a questionnaire to assess levels of context sensitivity in patients suffering chronic pain. In the laboratory we then conducted an experiment with patient volunteers to evaluate the association between being context (in)sensitive and the severity of the pain problem. In the clinic we interviewed patients to obtain knowledge about their emotion regulation strategies and their consistency with environmental cues. In addition, we developed a treatment module which we first pilot tested in a single-subject controlled study and subsequently incorporated into a treatment package designed for patients who suffer clinical levels of both distress and chronic pain. Finally, a randomized controlled trial was performed where we compared a standardized active treatment (an internet cognitive behavioral program) with a “hybrid” treatment which focused on emotion regulation and context sensitivity.

Three main finding

Our first main finding is that when we reliably measure social context (in)sensitivity, differences in sensitivity are related to the degree of the chronic pain problem. A pool of items was developed and tested as a way of measuring insensitive social responding and tested on over 100 people suffering persistent pain problems. The resulting questionnaire measures one form of context insensitivity, i.e. avoidance of expressing symptoms of pain and distress in a psychometrically sound manner. Moreover, rigid avoidance of expression was related to higher ratings of pain, disability, catastrophizing and suppression, thus supporting the idea that the construct may fuel both pain and distress. To establish a possible link between context insensitive social responding and pain and distress we devised an experiment where participants suffering persistent pain were asked to respond to social cues verbally. While participants talked we measured emotional responses and pain bothersomeness. We found a connection between context insensitive social responding and levels of pain and negative affect. In short, less sensitivity was associated with more negative affect not only when talking about the pain problem but also in other situations such as when asked to talk about something positive (i.e. a response insensitive to the social cue of “positive”). Taken together our findings demonstrate the important role of context and specifically responding in ways that are sensitive to the social cues in the environment. Insensitive responding was associated with greater pain problems, but also with more negative affect. This supports the transdiagnostic idea that context insensitivity may drive both pain and distress.

A second main finding is that patients suffering chronic pain and distress might benefit from a training program designed to increase sensitivity to social cues. We theorized that the development of chronic pain problems is driven by multiple factors where context sensitivity plays an important part and tested this idea in a variety of indirect ways. First, we worked with communication training based on validating the other person’s experiences as a way to increase attention to cues and the understanding of the social cues while decreasing negative affect. While this is indirect evidence, the results are in line with the theoretical idea. Second, a qualitative interview study showed that patients found social situations to often be provoking and difficult to deal with because of their pain problem. For example, the pain affected their image of their body and could lead to dressing in ways to “hide” their pain. This was in turn insensitive to certain context such as when visiting health care (patient doesn’t look like she/he is in pain) or at the work place (patient doesn’t look less able to work). Third, we developed a module for training context sensitive social responding. A five-session module focuses on communication patterns and assists patients in identifying important situations where good communication is desired. It provides skills training, based on validating communication, for altering patterns to be better in tune with the social context. A study using a controlled single-subject design should that this module was acceptable to patients, feasible to conduct, and notably helpful in reducing suffering due to pain for some participants. These findings demonstrated that training in social context sensitivity is thought to be helpful by patients and that skills can be trained to improve it. However, in line with the theoretical underpinnings, the results also suggested that context sensitivity training is not a “stand alone treatment” for most patients.

A third finding is that the treatment of patients suffering pain and distress can be improved. Although literature reviews have underscored the small effect sizes for treating patients with chronic pain and the lack of improvements over time, our randomized-controlled study provides hope. We found that a treatment designed to address the transdiagnostic emotion regulation factors thought to be driving both pain and distress—including a module on enhancing social context sensitivity—improves treatment results as compared to an active, standardized cognitive-behavioral program. Participants were patients with both a persistent pain problem and higher levels of depression or anxiety. They were randomly assigned to either an internet based cognitive-behavioral program already found to be effective or to a new “hybrid” emotion-focused treatment. The hybrid combines techniques for reducing avoidance of movement and techniques for reducing the avoidance of emotions. Responding in a way that is sensitive to the social context is one module in the treatment. Our results show that participants in the hybrid treatment were more satisfied and experienced a larger global improvement as relative to the CBTi program. Moreover, the hybrid had larger improvements on some key variables e.g. the reduction of depression, anxiety and catastrophizing as well as the increase of function. This study constitutes a clear step forward in our understanding and treatment of patients suffering chronic pain and distress.

New research questions generated

While this research has answered the questions posed, it also raises new ideas. These can be summarized into four areas:
1. Improving and developing the few existing methods for assessing context (in)sensitivity
2. Further development and use of laboratory paradigms for studying context (in)sensitivity
3. Investigations of the treatment module for context sensitivity to improve content
4. Identifying the mechanisms by which the hybrid treatment works by studying emotion regulation and context sensitivity as transdiagnostic factors during treatment.

Internationalization

We have developed and involved international researchers through our advisory board, a conference on the topic and participation in international meetings. Our scientific advisory board had two formal, face-to-face meetings; one to provide input before launching the project and one to assess results. In addition, we organized a topical conference on the role of context with several international speakers. Other international researchers have been engaged e.g. via conferences, visits, and correspondence.

Information transfer

We have been active in transferring information to the scientific and clinical communities. This has taken the form of scientific publications and conference presentations at international research meetings. In addition, we have actively participated in numerous workshops, and meetings of professional organizations.