Parental narrative style moderates the relation between pain-related attention and memory biases in youth with chronic pain.

ABSTRACT: Negatively biased pain memories robustly predict maladaptive pain outcomes in children. Both attention bias to pain and parental narrative style have been linked with the development of these negative biases, with previous studies indicating that how parents talk to their child about the pain might buffer the influence of children's attention bias to pain on the development of such negatively biased pain memories. This study investigated the moderating role of parental narrative style in the relation between pain-related attention and memory biases in a pediatric chronic pain sample who underwent a cold pressor task. Participants were 85 youth-parent dyads who reminisced about youth's painful event. Eye-tracking technology was used to assess youth's attention bias to pain information, whereas youth's pain-related memories were elicited 1 month later through telephone interview. Results indicated that a parental narrative style using less repetitive yes-no questions, more emotion words, and less fear words buffered the influence of high levels of youth's attention bias to pain in the development of negatively biased pain memories. Opposite effects were observed for youth with low levels of attention bias to pain. Current findings corroborate earlier results on parental reminiscing in the context of pain (memories) but stress the importance of matching narrative style with child characteristics, such as child attention bias to pain, in the development of negatively biased pain memories. Future avenues for parent-child reminiscing and clinical implications for pediatric chronic pain are discussed.

In search of conditioned pain: an experimental analysis.

ABSTRACT: There is an ongoing debate about whether pain can be classically conditioned, but surprisingly, evidence is scarce. Here, we report 3 experiments investigating this idea. In a virtual reality task, healthy participants were approached and touched near or on their hand with a coloured pen (blue or yellow). During acquisition, participants learned that one of the colours of the pen (CS+) was predictive of a painful electrocutaneous stimulus (ECS) whereas the other coloured pen (CS-) was not. During the test phase, more frequent reports of experiencing an US when none was delivered ("false alarm") for the CS+ vs CS- qualified as evidence of conditioned pain. Notable differences between experiments were that the US was delivered when the pen touched a spot between the thumb and index finger (experiment 1; n = 23), when it virtually touched the hand (experiment 2; n = 28) and when participants were informed that the pen caused pain rather than simply predicting something (experiment 3; n = 21). The conditioning procedure proved successful in all 3 experiments: Self-reported fear, attention, pain, fear, and US expectancy were higher ( P < 0.0005) for the CS+ than the CS-. There was no evidence for conditioned pain in experiment 1, but there was some evidence in experiments 2 and 3. Our findings indicate that conditioned pain may exist, albeit most likely in rare cases or under specific situations. More research is needed to understand the specific conditions under which conditioned pain exists and the underlying processes (eg, response bias).

Subliminal attentional bias modification training for itch.

Introduction: Itch is unpleasant and induces the urge to scratch. This is adaptive to remove the itch-inducing stimulus from the skin. Accordingly, itch draws attention to protect our bodily integrity. Recent studies investigated whether attention is preferentially drawn towards its location, i.e., attentional bias (AB), and also whether this bias could be changed in healthy individuals. So far, results are mixed concerning the existance of an attentional bias towards itch stimuli in healthy individuals as well as the impact of modifications. However, available studies have typically focused on conscious processing and might miss preconscious aspects of attention and potential biases at these stages. Methods: This study included 117 healthy individuals who underwent a subliminal Attentional Bias Modification (ABM)- training for itch based on a dot-probe paradigm with itch- related pictures. Participants were randomly assigned to a training towards itch group, a training away from itch group and a control group. This was done by manipulating the itch-target congruency of the dot-probe task during a training block. Pre- and post-training assessments were regular dot-probe tasks. Exploratorily, also attentional inhibition, cognitive flexibility and itch-related cognitions were assessed. Lastly, participants received an itchy stimulus on the inner forearm before and after the ABM-training to assess potential effects on itch sensitivity. Results: Results showed no AB towards itch across groups at baseline, i.e., pre-training, but an AB away from itch, hence, avoidance of itch, post-training. Further analyses showed that this effect was driven by an attentional bias away from itch in the control group, while there were no significant effects in the experimental groups. There was no effect on itch sensitivity. Conclusion: These findings are in line with recent studies on conscious ABM-training for itch and pain that also did not find significant training effects. Therefore, it is suggested that the field of AB might need to reconsider the current assessment of AB. Moreover, AB is probably a dynamic process that is highly dependent on current itch-related goals and relevance of itch in a specific situation. This suggests that processes probably differ in patients with chronic itch and that also ABM-training might work differently in these populations. Clinical trial registration: https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7561, identifier NTR7561.

Development and Evaluation of Linguistic Stimuli for Pain Research.

Linguistic stimuli are commonly used in research to investigate the processing of pain. To provide researchers with a dataset of pain-related and non-pain-related linguistic stimuli, this research investigated 1) the associative strength between pain-related words and the pain construct; 2) the pain-relatedness ratings of pain words; and 3) the variability in the relatedness of pain words within pain word classifications (eg, sensory pain words). In Study 1, 194 pain-related and matched non-pain-related words were retrieved by reviewing the pain-related attentional bias literature. In Study 2, adults with (n = 85) and without (n = 48) self-reported chronic pain completed a speeded word categorization paradigm and rated the pain-relatedness of a subset of pain words. Analyses revealed that 1) despite differences in associative strength of 11.3% of the words between chronic and non-chronic pain groups, no overall group difference was found, 2) the chronic pain group rated the pain words as more pain-related compared to the non-chronic pain group, and 3) there was variability in the relatedness of pain words within pain word classifications. The findings highlight the importance of validating linguistic pain stimuli. The resulting dataset is openly accessible and new published sets can be added to the Linguistic Materials for Pain (LMaP) Repository. PERSPECTIVE: This article presents the development and preliminary evaluation of a large pool of pain-related and non-pain-related words in adults with and without self-reported chronic pain. Findings are discussed and guidelines are offered to select the most suitable stimuli for future research.

The Influence of Children's Pain-Related Attention Shifting Ability and Pain Catastrophizing Upon Negatively Biased Pain Memories in Healthy School Children.

The current study investigated the influence of children's ability to flexibly shift attention toward and away from pain information on the development of negatively biased pain memories, thereby employing a direct measure of attention control reliant on behavioral responses in the context of pain (ie, an attention switching task). The direct influence of children's attention-shifting ability and pain catastrophizing as well as the moderating role of this shifting ability in the relationship between pain catastrophizing and the development of negatively biased pain memories was examined. Healthy school children (N = 41; 9-15 years old) received painful heat stimuli and completed measures of state and trait pain catastrophizing. They then performed an attention-switching task wherein they had to shift attention between personally relevant pain-related and neutral cues. Two weeks after the painful task, children's pain-related memories were elicited via telephone. Findings indicated that children's reduced ability to disengage attention away from pain information predicted more fear memory bias 2 weeks later. Children's pain-related attention-shifting ability did not moderate the relationship between children's pain catastrophizing and negatively biased pain memories. Findings highlight the contribution of children's attention control skills in the development of negatively biased pain memories. PERSPECTIVE: Results of the current study indicate that children with a reduced ability to shift attention away from pain information are at risk for developing negatively biased pain memories. Findings can inform interventions to minimize the development of these maladaptive negatively biased pain memories by targeting pain-relevant attention control skills in children.

Youth baseline and state pain-related injustice appraisals are associated with emotional responses of anger and sadness: An experimental study.

Background: Youth pain-related injustice appraisals are associated with adverse functioning; however, mechanisms by which injustice appraisals exert their impact have yet to be elucidated. Adult injustice literature suggests anger, sadness, and attention bias to anger (AB) as potential mechanisms. This study examined the effects of injustice appraisals in a healthy youth sample by applying a justice violation manipulation. We hypothesized the justice violation condition to lead to worse pain outcomes with effects mediated by anger, sadness, and AB as compared to the control condition. We further explored associations between both baseline and state injustice appraisals and anger, sadness, and AB across conditions. Methods: A 2 × 2 time by condition design was used to test hypotheses. 133 healthy youth aged 9-16 years old completed two cold pressor tasks (CPTs). In the experimental (i.e., justice violation) group, participants were initially told to complete one CPT, but were told afterwards to perform it again due to experimenter negligence. In the control group, no justice violation occurred. Baseline injustice appraisals and pain catastrophizing were assessed with the Injustice Experience Questionnaire and Pain Catastrophizing Scale for Children; state outcomes (i.e., injustice, catastrophizing, anger, sadness) were assessed after CPTs. AB was indexed using a dot-probe task. Results: Findings indicated no effects of the justice violation on pain outcomes or associated mechanisms, nor on injustice appraisals, suggesting manipulation failure. However, across conditions, baseline and state injustice appraisals were positively associated with anger and sadness, but not with AB. Conclusions: Despite the experimental justice violation failing to elicit differential injustice appraisals across conditions, the current study supports both anger and sadness as key emotional responses associated with pain-related injustice appraisals in a healthy youth sample.

What can we learn about selective attention processes in individuals with chronic pain using reaction time tasks? A systematic review and meta-analysis.

ABSTRACT: Information-processing biases such as attentional, interpretation, and memory biases are believed to play a role in exacerbating and maintaining chronic pain (CP). Evidence suggests that individuals with CP show attentional bias toward pain-related information. However, the selective attentional processes that underpin this bias are not always well outlined in the literature. To improve current understanding, a systematic review was performed using a descriptive synthesis of reaction time-based studies. A random-effects meta-analysis was added to explore whether the results of previous meta-analyses would be confirmed using studies with a larger sample size. For this review, 2008 studies were screened from 4 databases, of which 34 (participant n = 3154) were included in the review and a subset of 15 (participant n = 1339) were included in the meta-analysis. Review results were summarised by producing a descriptive synthesis for all studies. Meta-analysis results indicated a mild significant attentional bias toward sensory pain-related information (k = 15, g = 0.28, 95% CI [0.16, 0.39], I 2 = 43.2%, P = 0.038), and preliminary evidence of significant moderate bias towards affective pain-related information (k = 3, g = 0.48, 95% CI [0.23, 0.72], I 2 = 7.1%, P = 0.341) for CP groups compared with control groups. We explored the main tasks, stimuli, and CP subtypes used to address attentional biases and related processes. However, variation across studies did not allow for a decisive conclusion about the role of stimulus, task type, or related attentional processes. In addition, a table of CP attention-related models was produced and tested for reliability. Finally, other results and recommendations are discussed.

The relation between children's attention bias to pain and children's pain-related memory biases is moderated by parental narrative style.

Children's heightened attention to pain and parental narrative style have been linked to the development of negatively-biased pain memories in children (i.e., recalling higher levels of pain and fear than initially reported, which robustly predicts maladaptive pain outcomes). However, the interplay between child attention bias and parental narrative style remains to be assessed. This study aims to fill this gap using enhanced paradigms assessing children's cognitive biases for cues signaling actual pain. Healthy school children (N = 63; 9-15 years old) received painful heat stimuli while performing a spatial cueing task measuring attention bias to cues signaling actual pain. Parent-child interaction upon completion of the painful task, was coded for parental narrative style (i.e., elaboration, repetition and evaluation). Children's pain-related memories were elicited two weeks later. Findings indicated that children showed an attention bias to cues signaling pain. Furthermore, children who were hypervigilant to pain cues benefitted from parents elaborating more about the pain experience, while children who avoided pain cues developed more negatively-biased pain memories if parents had a more elaborative style compared to a more evaluative parental style. In conclusion, this study suggests that optimal ways to talk about children's pain depend upon child characteristics (i.e., children's attention bias to pain).

No preconscious attentional bias towards itch in healthy individuals.

Rapidly attending towards potentially harmful stimuli to prevent possible damage to the body is a critical component of adaptive behavior. Research suggests that individuals display an attentional bias, i.e., preferential allocation of attention, for consciously perceived bodily sensations that signal potential threat, like itch or pain. Evidence is not yet clear whether an attentional bias also exists for stimuli that have been presented for such a short duration that they do not enter the stream of consciousness. This study investigated whether a preconscious attentional bias towards itch-related pictures exists in 127 healthy participants and whether this can be influenced by priming with mild itch-related stimuli compared to control stimuli. Mild itch was induced with von Frey monofilaments and scratching sounds, while control stimuli where of matched modalities but neutral. Attentional bias was measured with a subliminal pictorial dot-probe task. Moreover, we investigated how attentional inhibition of irrelevant information and the ability to switch between different tasks, i.e., cognitive flexibility, contribute to the emergence of an attentional bias. Attentional inhibition was measured with a Flanker paradigm and cognitive flexibility was measured with a cued-switching paradigm. Contrary to our expectations, results showed that participants attention was not biased towards the itch-related pictures, in facts, attention was significantly drawn towards the neutral pictures. In addition, no effect of the itch-related priming was observed. Finally, this effect was not influenced by participants' attentional inhibition and cognitive flexibility. Therefore, we have no evidence for a preconscious attentional bias towards itch stimuli. The role of preconscious attentional bias in patients with chronic itch should be investigated in future studies.

The Effect of a Pain Educational Video Upon Child Pain-Related Memory and the Moderating Role of Parental Pain- and Non-Pain-Attending Verbalizations: An Experimental Lab-Based Study.

OBJECTIVES: Early memories of pain contribute to fear and may underlie the maintenance and development of chronic pain into adulthood. Accordingly, understanding determinants that may impact children's pain memory development is key. This study examined (a) the effect of a brief engaging pain educational video in healthy children before undergoing an experimental pain task upon children's recalled pain intensity and pain-related fear and (b) the moderating role of parental pain- and non-pain-attending verbalizations before and after the pain task. METHODS: Seventy-seven children (8-15 years old) participated in an experimental heat pain task, including actual heat pain stimuli delivered through a thermode on their forearm. Children were randomized to the experimental group (i.e., watching a pain educational video) or the control group (i.e., no video). Children's recalled pain intensity and pain-related fear were elicited 2 weeks later. RESULTS: Findings showed that recalled pain intensity (but not recalled pain-related fear) of children who watched the pain educational video was significantly lower compared to the control group (p = .028). Further, parental pain-attending verbalizations before the pain task moderated the impact of the video upon children's recalled pain intensity (p = .038). Specifically, children in the control group, but not the experimental group, whose parents used less pain-attending verbalizations recalled higher pain intensity, whereas children whose parents used more pain-attending verbalizations recalled lower pain intensity. CONCLUSIONS: As children's pain memories have important implications for pain assessment, treatment, and health across the lifespan, these findings might have important implications for the prevention of development or maintenance of maladaptive pain-related outcomes.

Gamified Web-Delivered Attentional Bias Modification Training for Adults With Chronic Pain: Protocol for a Randomized, Double-blind, Placebo-Controlled Trial.

BACKGROUND: To date, research has found variable success in using attentional bias modification training (ABMT) procedures in pain samples. Several factors could contribute to these mixed findings, including boredom and low motivation. Indeed, training paradigms are repetitive, which can lead to disengagement and high dropout rates. A potential approach to overcoming some of these barriers is to attempt to increase motivation and engagement through gamification (ie, the use of game elements) of this procedure. To date, research has yet to explore the gamified format of ABMT for chronic pain and its potential for the transfer of benefits. OBJECTIVE: The aim of this study is to investigate the effects of a gamified web-delivered ABMT intervention in a sample of adults with chronic pain via a randomized, double-blind, placebo-controlled trial. METHODS: A total of 120 adults with chronic musculoskeletal pain, recruited from clinical (hospital outpatient waiting list) and nonclinical (wider community) settings, will be included in this randomized, double-blind, placebo-controlled, 3-arm trial. Participants will be randomly assigned to complete 6 web-based sessions of dot-probe nongamified sham control ABMT, nongamified standard ABMT, or gamified ABMT across a period of 3 weeks. Active ABMT conditions will aim to train attention away from pain-relevant words. Participant outcomes will be assessed at pretraining, during training, immediately after training, and at the 1-month follow-up. Primary outcomes include pain intensity, pain interference, and behavioral and self-reported engagement. Secondary outcomes include attentional bias for pain, anxiety, depression, interpretation bias for pain, and perceived improvement. RESULTS: The ethical aspects of this research project have been approved by the human research ethics committees of the Royal Brisbane and Women's Hospital (HREC/2020/QRBW/61743) and Queensland University of Technology (2000000395). Study recruitment commenced in August 2021 and is ongoing. Data collection and analysis are expected to be concluded by October 2022 and January 2023, respectively. CONCLUSIONS: This trial will be the first to evaluate the effects of gamification techniques in a pain ABMT intervention. The findings will provide important information on the potential therapeutic benefits of gamified pain ABMT programs, shed light on the motivational influences of certain game elements in the context of pain, and advance our understanding of chronic pain. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12620000803998; https://anzctr.org.au/ACTRN12620000803998.aspx. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/32359.

Can perioperative psychological interventions decrease the risk of postsurgical pain and disability? A systematic review and meta-analysis of randomized controlled trials.

ABSTRACT: Many patients experience pain after surgery. Psychological factors such as emotion and cognition are shown to be associated with the development of acute and chronic postsurgical pain (CPSP). Therefore, the question arises whether targeting these psychological factors can reduce negative postsurgical outcomes. The aim of the current review was to investigate the efficacy of perioperative psychological interventions in reducing (sub)acute postsurgical pain and CPSP and disability in adults. Randomized controlled trials were identified through 4 databases (Web of Science, PsychINFO, PubMed, and Cumulative Index to Nursing and Allied Health Literature [CINAHL]). The outcomes of interest were (sub)acute (ie, within 3 months after surgery) and chronic (>3 months after surgery) pain and disability. After screening, 21 studies were included in the final analyses. It was found that psychological interventions significantly reduced (sub)acute pain (d = -0.26, 95% confidence interval [CI] [-0.48 to -0.04]) and disability (d = -0.43, 95% CI [-0.84 to -0.03]) as well as CPSP (d = -0.33, 95% CI [-0.61 to -0.06]) and disability (d = -0.43, 95% CI [-0.68 to -0.18]). In addition, interventions delivered after surgery and interventions delivered by a psychologist tended to be more effective than interventions delivered before surgery and interventions delivered by another healthcare provider. Furthermore, the current review points to the need for more research to determine which specific type of intervention may be most beneficial for surgical patients. Finally, the current review identified that research in this domain has concerns regarding bias in missing outcome data due to withdrawal and drop out.

The Impact of Parental Presence on Their Children During Painful Medical Procedures: A Systematic Review.

OBJECTIVE: Whether parental presence during their children's painful medical procedures is advantageous with regard to children's pain-related outcomes is questionable. Research on this topic is equivocal, and additional questions, such as whether levels of parental involvement may play a role as well, remain to be addressed. The purpose of this systematic review is to summarize and critically appraise the literature on the impact of parental presence vs absence during their children's painful medical procedures on the child's pain-related outcomes. METHODS: The review protocol was registered on Prospero (ID CRD42018116614). A systematic search in PubMed, Web of Science, and PsycArticles resulted in 22 eligible studies incorporating 2,157 participants. Studies were considered eligible if they included children (≤18 years old) undergoing a painful medical procedure and compared parental presence and/or involvement with parental absence during the procedure. RESULTS: The children's pain-related outcomes included self-reported pain intensity, self-reported fear, anxiety and distress, observed pain-related behavior, and physiological parameters. Overall, evidence points in the direction of beneficial effects of parental presence vs absence with regard to children's self-reported pain intensity and physiological parameters, whereas mixed findings were recorded for children's self-reported fears, anxiety and distress, and observed pain-related behaviors. CONCLUSIONS: To provide clear recommendations on how to involve the parent during the procedure, as well as for which type of children and parents parental presence has the best effects, further research is needed, as indicated in this review.

Racial disparities in observers' attention to and estimations of others' pain.

ABSTRACT: Research has demonstrated racial disparities in pain care such that Black patients often receive poorer pain care than White patients. Little is known about mechanisms accounting for the emergence of such disparities. The present study had 2 aims. First, we examined whether White observers' attentional processing of pain (using a visual search task [VST] indexing attentional engagement to and attentional disengagement from pain) and estimation of pain experience differed between White vs Black faces. Second, we examined whether these differences were moderated by (1) racially biased beliefs about pain experience and (2) the level of pain expressed by Black vs White faces. Participants consisted of 102 observers (87 females) who performed a VST assessing pain-related attention to White vs Black avatar pain faces. Participants also reported on racially biased beliefs about White vs Black individuals' pain experience and rated the pain intensities expressed by White and Black avatar faces. Results indicated facilitated attentional engagement towards Black (vs White) pain faces. Furthermore, observers who more strongly endorsed the belief that White individuals experience pain more easily than Black individuals had less difficulty disengaging from Black (vs White) pain faces. Regarding pain estimations, observers gave higher pain ratings to Black (vs White) faces expressing high pain and White (vs Black) faces expressing no pain. The current findings attest to the importance of future research into the role of observer attentional processing of sufferers' pain in understanding racial disparities in pain care. Theoretical and clinical implications are discussed, and future research directions are outlined.

Clinical relevance of attentional biases in pediatric chronic pain: an eye-tracking study.

ABSTRACT: Attentional biases have been posited as one of the key mechanisms underlying the development and maintenance of chronic pain and co-occurring internalizing mental health symptoms. Despite this theoretical prominence, a comprehensive understanding of the nature of biased attentional processing in chronic pain and its relationship to theorized antecedents and clinical outcomes is lacking, particularly in youth. This study used eye-tracking to assess attentional bias for painful facial expressions and its relationship to theorized antecedents of chronic pain and clinical outcomes. Youth with chronic pain (n = 125) and without chronic pain (n = 52) viewed face images of varying levels of pain expressiveness while their eye gaze was tracked and recorded. At baseline, youth completed questionnaires to assess pain characteristics, theorized antecedents (pain catastrophizing, fear of pain, and anxiety sensitivity), and clinical outcomes (pain intensity, interference, anxiety, depression, and posttraumatic stress). For youth with chronic pain, clinical outcomes were reassessed at 3 months to assess for relationships with attentional bias while controlling for baseline symptoms. In both groups, youth exhibited an attentional bias for painful facial expressions. For youth with chronic pain, attentional bias was not significantly associated with theorized antecedents or clinical outcomes at baseline or 3-month follow-up. These findings call into question the posited relationships between attentional bias and clinical outcomes. Additional studies using more comprehensive and contextual paradigms for the assessment of attentional bias are required to clarify the ways in which such biases may manifest and relate to clinical outcomes.

When, why, and how do People Deviate from Physical Distancing Measures During the COVID-19 Pandemic: A Mixed-Methods Study.

INTRODUCTION: To limit the spread of COVID-19, many countries, including Belgium, have installed physical distancing measures. Yet, adherence to these newly installed behavioral measures has been described as challenging and effortful. Based on the Health Action Process Approach (HAPA) model, this study performed an in-depth evaluation of when, why, and how people deviated from the physical distancing measures. METHODS: An online mixed-method study was conducted among Belgian adults (N = 2055) in the beginning of May 2020. Participants were recruited via an open call through email and social media platforms, using snowball sampling. Conditions wherein people deviated from the physical distancing measures were assessed by means of an open-ended question. HAPA determinants were assessed in a quantitative way. RESULTS: Half of the sample reported to deviate from the measures. Further, deviation from the measures was associated with each determinant outlined by the HAPA. Findings highlight that many people deviated from the measures because of their need for social contact. The majority of the people who deviated from the measures stated that they carefully weighed the risks of their behavior. CONCLUSIONS: Need for social contact pushed people to deviate from physical distancing measures in a deliberate manner. Potential areas for future interventions aimed at promoting adherence to physical distancing measures and enhancing psychosocial well-being are discussed.

Attentional Bias Modification Training for Itch: A Proof-of-Principle Study in Healthy Individuals.

Itch draws our attention to allow imposing action against bodily harm (e.g., remove insects). At the same time, itch is found to interfere with ongoing tasks and daily life goals. Despite the key role of attention in itch processing, interventions that train individuals to automatically disengage attention from itch cues are lacking. The present proof-of-principle attention bias modification (ABM) training study was aimed at investigating whether attention to itch as well as sensitivity to mild itch can be changed. Healthy volunteers were randomized over three ABM-training conditions. Training was done via a modified pictorial dot-probe task. In particular, participants were trained to look away from itch stimuli (n = 38), toward itch stimuli (n = 40) or not trained toward or away from itch at all (sham training, n = 38). The effects of the ABM-training were tested primarily on attention to itch pictures. Secondarily, it was investigated whether training effects generalized to alterations in attention to itch words and mechanical itch sensitivity. The ABM-training did not alter attention toward the itch pictures, and there was no moderation by baseline levels of attention bias for itch. Also, attention bias to the itch words and itch sensitivity were not affected by the ABM-training. This study was a first step toward trainings to change attention toward itch. Further research is warranted to optimize ABM-training methodology, for example increasing motivation of participants. Eventually, an optimized training could be used in patient populations who suffer most from distraction by their symptoms of itch. Clinical Trial Registration: Identifier: NL6134 (NTR6273). The website URL is: https://www.trialregister.nl/.