Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives.

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

The impact of the social context on the development of secondary hyperalgesia: an experimental study.

ABSTRACT: Social support has been shown to reduce pain ratings and physiological responses to acute pain stimuli. Furthermore, this relationship is moderated by adult attachment styles. However, these effects have not been characterized in experimentally induced symptoms of chronic pain, such as secondary hyperalgesia (SH) which is characterized by an increased sensitivity of the skin surrounding an injury. We aimed to examine whether social support by handholding from a romantic partner can attenuate the development of experimentally induced SH. Thirty-seven women, along with their partners, participated in 2 experimental sessions 1 week apart. In both sessions, SH was induced using an electrical stimulation protocol. In the support condition, the partner was seated across from the participant holding the participant's hand during the electrical stimulation, whereas in the alone condition, the participant went through the stimulation alone. Heart rate variability was measured for both the participant as well as the partner before, during, and after the stimulation. We found that the width of the area of hyperalgesia was significantly smaller in the support condition. Attachment styles did not moderate this effect of social support on the area width. Increasing attachment avoidance was associated with both a smaller width of hyperalgesia and a smaller increase in the sensitivity on the stimulated arm. For the first time, we show that social support can attenuate the development of secondary hyperalgesia and that attachment avoidance may be associated with an attenuated development of secondary hyperalgesia.

"What can her body do?" Reducing weight stigma by appreciating another person's body functionality.

OBJECTIVE: Weight stigma is prevalent across multiple life domains, and negatively affects both psychological and physical health. Yet, research into weight stigma reduction techniques is limited, and rarely results in reduced antipathy toward higher-weight individuals. The current pre-registered study investigated a novel weight stigma reduction intervention. We tested whether a writing exercise focusing on body functionality (i.e., everything the body can do, rather than how it looks) of another person leads to reductions in weight stigma. METHOD: Participants were 98 women (Mage = 23.17, Range = 16-63) who viewed a photograph of a higher-weight woman, "Anne," and were randomised to complete a writing exercise either describing what "Anne's" body could do (experimental group) or describing her home (active control group). Facets of weight stigma were assessed at pretest and posttest. RESULTS: At posttest, the experimental group evidenced higher fat acceptance and social closeness to "Anne" compared with the active control group. However, no group differences were found in attribution complexity, responsibility, and likeability of "Anne". CONCLUSIONS: A brief body functionality intervention effectively reduced some, but not all, facets of weight stigma in women. This study provides evidence that functionality-focused interventions may hold promise as a means to reduce weight stigma.

Freeze-like responses to pain in humans and its modulation by social context.

BACKGROUND: Maladaptive defensive responses such as excessive avoidance behavior have received increasing attention as a main mechanism for the development and maintenance of chronic pain complaints. However, another defensive response which is commonly studied in animals as a proxy for fear is freezing behavior. No research to date has investigated human freezing behavior in the context of pain. In addition, there is an increasing realization that social context can affect pain-relevant processes such as pain experience and pain behavior but less is known about the effects of social context on defensive responses to pain. Hence, this study investigated freezing behavior and facial pain expression in the context of pain, and their modulation by social context. METHODS: Healthy, pain-free participants (N = 39) stood on a stabilometric force platform in a threatening or safe social context, which was manipulated using angry or happy facial stimuli. In some trials, an auditory cue (conditioned stimulus; CS) predicted the occurrence of painful electrocutaneous stimulus (unconditioned stimulus; pain-US). We assessed body sway (an index of freezing), heart rate, facial pain expression, self-reported pain intensity, unpleasantness, and pain-US expectancy during the CS and the context alone (no CS). RESULTS: The results were mixed. Neither the anticipation of pain, nor social context affected body sway. Heart rate and painful facial expression were reduced in the threatening social context at high anxiety levels. A threatening social context also elicited higher pain-US expectancy ratings. In sum, a threatening social context increases the expectation of pain, but reduces the facial expression of pain and lowers heart rate in highly anxious individuals.

Hide Your Pain: Social Threat Increases Pain Reports and Aggression, but Reduces Facial Pain Expression and Empathy.

Earlier research studying the effects of social threat on the experience and expression of pain led to mixed results. In this study, female participants (N = 32) came to the lab with 2 confederates. Both confederates administered a total of 10 painful electrocutaneous stimuli to the participant. The framing of the administration was manipulated in a within-subjects design: In the low social threat condition the participant was told that the confederate could choose between 10 and 20 pain stimuli, thus they believed that this confederate chose to administer the minimum allowed number of pain stimuli. In the high social threat condition the confederate had a choice between 1 and 10 stimuli, thus they believed that this confederate chose to administer the maximum allowed number of stimuli. Participants reported on the intensity, unpleasantness, and threat value of the painful stimuli, and their facial expression was recorded. Moreover, aggression and empathy toward the confederates were assessed. As hypothesized, participants reported increased pain intensity, unpleasantness, and threat in the high social threat condition compared to the low social threat condition, but showed less facial pain expression. Finally, participants exhibited increased aggression and reduced empathy toward the confederate in the high social threat condition. PERSPECTIVE: Social threat reduces painful facial expression, but simultaneously increases pain reports, leading to a double burden of the person in pain. Additionally, social threat affected social relationships by increasing aggression and reducing empathy for the other.

Effects of (in)validation and plain versus technical language on the experience of experimentally induced pain: A computer controlled simulation paradigm.

BACKGROUND AND OBJECTIVES: Amongst social contextual influences on pain, the manner in which pain and painful procedures are communicated to patients is considered an important contributor to the subjective experience of pain. Threatening information, e.g., by the use of technical language, is suggested to increase pain reports. Validation, or communicating understanding towards another person reporting personal experiences, is suggested to reduce pain. The current study examines effects of both information language (technical vs. plain language) and validation (validation vs. invalidation) on the subjective experience of experimentally induced pain. METHODS: Pain-free participants (N = 132) were randomly assigned to one of four groups as formed by manipulations of validation and information language. After reading a description concerning the upcoming thermal stimulus formulated in technical or plain language, participants engaged in a computer controlled simulation (CCS; based on virtual reality technology). Participants received three thermal stimuli while interacting with an avatar who either validated or invalidated their experience during the CCS. Pain intensity and pain unpleasantness were assessed after each stimulus. RESULTS: The validation manipulation showed to be effective, but the information language manipulation did not induce differential threat expectancies. Results show no effect of validation or information language on subjective pain reports. LIMITATIONS: Suboptimality of the information language manipulation and shortcomings of the CCS procedure might account for current findings. CONCLUSIONS: The study offers an interesting model for the further experimental study of isolated and combined effects of (social) contextual factors on pain. Diverse future research avenues are discussed.

Parental emotion and pain control behaviour when faced with child's pain: the emotion regulatory role of parental pain-related attention-set shifting and heart rate variability.

This study investigated the moderating role of parental pain-related attention-set shifting and heart rate variability (HRV) for parental distress and pain control behaviour when faced with their child's pain. Participants were 54 schoolchildren and one of their parents. Parental HRV was assessed at study commencement followed by a cued-switching task indexing parental ability to flexibly shift attention between pain-related and neutral attentional sets. In a subsequent phase, parents observed their child perform a cold-pressor task [CPT], allowing for assessment of parental pain control behavior (indexed by latency to stop their child's CPT performance) and parental distress-assessed through self-report following observation of child CPT performance. Findings indicated that parental facilitated attentional shifting (ie, engage) towards a pain-related attentional set contributed to higher levels of pain control behaviour when faced with increasing levels of child facial display of pain. Pain control behaviour among parents who demonstrated impeded attentional shifting to a pain-related attentional set was equally pronounced regardless of low or high levels of child pain expression. Parental ability to shift attention away (ie, disengage) from a pain-related set to a neutral set did not impact findings. Results further indicated that although high levels of parental HRV buffer the impact of child facial pain display on parental emotional distress and pain control behaviour, low levels of HRV constitute a risk factor for higher levels of parental distress and pain control behaviour when faced with increased child facial pain display. Theoretical/clinical implications and further research directions are discussed.

Pain, Please: An Investigation of Sampling Bias in Pain Research.

Experimental pain research frequently relies on the recruitment of volunteers. However, because experimental pain research often involves unpleasant and painful sensations, it may be especially susceptible to sampling bias. That is, volunteers in experimental pain research might differ from nonvolunteers on several relevant variables that could affect the generalizability and external validity of the research. We conducted 2 studies to investigate potential sampling bias in experimental pain research. In study 1 we assessed participants' (N = 275; age = 17-30 years) perceived likelihood of participating in pain research. Pain catastrophizing, fear of pain, illness and injury sensitivity, depression, anxiety, sensation-seeking, gender identity, body appreciation, and social desirability were also assessed as potential predictors of the likelihood to participate. In study 2, participants (N = 87; Age = 18-31 years) could sign up for 2 nearly identical studies, with only one involving painful sensations. Thirty-six participants signed up for the pain study and 51 participants signed up for the no-pain study. Study 1 showed that lower levels of fear of pain, higher levels of sensation-seeking, and older age predicted the perceived likelihood of participating in pain research. Study 2 showed significantly higher levels of sensation-seeking in participants who signed up for the pain study compared with those who signed up for the no-pain study. The implications of these findings for future research, as well as the clinical conclusions on the basis of experimental pain research, are discussed. PERSPECTIVE: Intention to participate in experimental pain research was associated with less fear of pain, higher sensation-seeking, and older age. Actual participation in experimental pain research was associated with higher sensation-seeking. This potential sampling bias in studies involving painful stimuli could limit external validity and generalizability of pain research.

The Influence of Social Threat on Pain, Aggression, and Empathy in Women.

Only one published study has investigated the effect of a threatening social context on the perception and expression of pain, showing that social threat leads to increased pain reports but reduced nonverbal pain expression. The current study aimed to replicate and extend these findings to further explore the effects of a threatening social context. Healthy, female participants (N = 71) received 10 electrocutaneous stimuli delivered by a confederate. They were led to believe that the confederate was requested to administer 10 painful stimuli (control group) or that the confederate deliberately chose to deliver 10 painful stimuli when given the choice to deliver between 1 to 10 painful stimuli (social threat group). Self-reported pain intensity, unpleasantness, threat value of pain, and painful facial expression were assessed. Additionally, empathy and aggression toward the confederate were investigated. Social threat did not affect painful facial expression or self-reported pain intensity, but led to increased aggression toward the confederate. Moreover, perceived social threat predicted the threat value of pain and reduced empathy toward the confederate. We were not able to replicate the previously reported dissociation between pain reports and pain expression as a result of social threat. However, social threat was associated with an increased threat value of pain, increased aggression, and reduced empathy. PERSPECTIVE: A threatening social context affects how threatening pain is perceived and has interpersonal consequences such as increased aggression and reduced empathy, thereby creating a double burden on the individual suffering from pain.

Expand Your Horizon: A programme that improves body image and reduces self-objectification by training women to focus on body functionality.

This study tested Expand Your Horizon, a programme designed to improve body image by training women to focus on the functionality of their body using structured writing assignments. Eighty-one women (Mage=22.77) with a negative body image were randomised to the Expand Your Horizon programme or to an active control programme. Appearance satisfaction, functionality satisfaction, body appreciation, and self-objectification were measured at pretest, posttest, and one-week follow-up. Following the intervention, participants in the Expand Your Horizon programme experienced greater appearance satisfaction, functionality satisfaction, and body appreciation, and lower levels of self-objectification, compared to participants in the control programme. Partial eta-squared effect sizes were of small to medium magnitude. This study is the first to show that focusing on body functionality can improve body image and reduce self-objectification in women with a negative body image. These findings provide support for addressing body functionality in programmes designed to improve body image.

Threatening social context facilitates pain-related fear learning.

UNLABELLED: This study investigated the effects of a threatening and a safe social context on learning pain-related fear, a key factor in the development and maintenance of chronic pain. We measured self-reported pain intensity, pain expectancy, pain-related fear (verbal ratings and eyeblink startle responses), and behavioral measures of avoidance (movement-onset latency and duration) using an established differential voluntary movement fear conditioning paradigm. Participants (N = 42) performed different movements with a joystick: during fear acquisition, movement in one direction (CS+) was followed by a painful stimulus (pain-US) whereas movement in another direction (CS-) was not. For participants in the threat group, an angry face was continuously presented in the background during the task, whereas in the safe group, a happy face was presented. During the extinction phase the pain-US was omitted. As compared to the safe social context, a threatening social context led to increased contextual fear and facilitated differentiation between CS+ and CS- movements regarding self-reported pain expectancy, fear of pain, eyeblink startle responses, and movement-onset latency. In contrast, self-reported pain intensity was not affected by social context. These data support the modulation of pain-related fear by social context. PERSPECTIVE: A threatening social context leads to stronger acquisition of (pain-related) fear and simultaneous contextual fear but does not affect pain intensity ratings. This knowledge may aid in the prevention of chronic pain and anxiety disorders and shows that social context might modulate pain-related fear without immediately affecting pain intensity itself.

Competing goals attenuate avoidance behavior in the context of pain.

UNLABELLED: Current fear-avoidance models consider pain-related fear as a crucial factor in the development of chronic pain. However, pain-related fear often occurs in a context of multiple, competing goals. This study investigated whether pain-related fear and avoidance behavior are attenuated when individuals are faced with a pain avoidance goal and another valued but competing goal, operationalized as obtaining a monetary reward. Fifty-five healthy participants moved a joystick toward different targets. In the experimental condition, a movement to one target (conditioned stimulus [CS+]) was followed by a painful unconditioned stimulus (pain-US) and a rewarding unconditioned stimulus (reward-US) on 50% of the trials, whereas the other movement (nonreinforced conditioned stimulus [CS-]) movement was not. In the control condition, the CS+ movement was followed by the pain-US only. Results showed that pain-related fear was elevated in response to the CS+ compared to the CS- movement, but that it was not influenced by the reward-US. Interestingly, participants initiated a CS+ movement slower than a CS- movement in the control condition but not in the experimental condition. Also, in choice trials, participants performed the CS+ movement more frequently in the experimental than in the control condition. These results suggest that the presence of a valued competing goal can attenuate avoidance behavior. PERSPECTIVE: The current study provides experimental evidence that both pain and competing goals impact on behavioral decision making and avoidance behavior. These results provide experimental support for treatments of chronic pain that include an individual's pursuit of valuable daily life goals, rather than limiting focus to pain reduction only.

Factor structure, reliability, and known groups validity of the German version of the Childhood Trauma Questionnaire (Short-form) in Swiss patients and nonpatients.

The Childhood Trauma Questionnaire-Short Form is the most widely used instrument to assess childhood trauma and has been translated into 10 languages. However, research into validity and reliability of these translated versions is scarce. The present study aimed to investigate the factor structure, internal consistency, reliability, and known-groups validity of the German Childhood Trauma Questionnaire-Short Form (Bernstein & Fink, 1998). Six-hundred and sixty-one clinical and nonclinical participants completed the German Childhood Trauma Questionnaire-Short Form. A confirmatory factor analysis was conducted to assess the 5-factor structure of the original Childhood Trauma Questionnaire-Short Form. To investigate known-groups validity, the confirmatory factor analysis latent factor levels between clinical and nonclinical participants were compared. The original 5-factor structure was confirmed, with only the Physical Neglect scale showing rather poor fit. As a conclusion, the results support the validity and reliability of the German Childhood Trauma Questionnaire-Short Form. It is recommended to use the German Childhood Trauma Questionnaire-Short Form to assess experiences of childhood trauma.