Threatening Social Context Facilitates Pain-Related Fear Learning

  • Kai Karos
    Address reprint requests to Kai Karos, MSc, Department of Psychology, University of Leuven, Tiensestraat 102, Box 3726, 3000 Leuven, Belgium.
    Research Group on Health Psychology, University of Leuven, Leuven, Belgium
    Search for articles by this author
  • Ann Meulders
    Research Group on Health Psychology, University of Leuven, Leuven, Belgium

    Center for Excellence on Generalization Research in Health and Psychopathology, University of Leuven, Leuven, Belgium
    Search for articles by this author
  • Johan W.S. Vlaeyen
    Research Group on Health Psychology, University of Leuven, Leuven, Belgium

    Center for Excellence on Generalization Research in Health and Psychopathology, University of Leuven, Leuven, Belgium

    Department of Clinical Psychological Sciences, Maastricht University, Maastricht, The Netherlands
    Search for articles by this author
Published:December 12, 2014DOI:


      • A threatening social context facilitates differential acquisition of pain-related fear.
      • The facilitation is evident in self-report and psychophysiological indices of fear.
      • A threatening social context leads to contextual fear.
      • Social context does not affect pain intensity ratings.


      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.


      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.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Asmundson G.J.G.
        • Taylor S.
        Role of anxiety sensitivity in pain-related fear and avoidance.
        J Behav Med. 1996; 19: 577-586
        • Blumenthal T.D.
        • Cuthbert B.N.
        • Filion D.L.
        • Hackley S.
        • Lipp O.V.
        • van Boxtel A.
        Committee report: Guidelines for human startle eyeblink electromyographic studies.
        Psychophysiology. 2005; 42: 1-15
        • Boddez Y.
        • Baeyens F.
        • Luyten L.
        • Vansteenwegen D.
        • Hermans D.
        • Beckers T.
        Rating data are underrated: Validity of US expectancy in human fear conditioning.
        J Behav Ther Exp Psychiatry. 2013; 44: 201-206
        • Bouton M.E.
        Learning and Behavior: A Contemporary Synthesis.
        Sinauer Associates, Inc., Sunderland, MA2007
        • Bradley B.P.
        • Mogg K.
        • Falla S.J.
        • Hamilton L.R.
        Attentional bias for threatening facial expressions in anxiety: Manipulation of stimulus duration.
        Cogn Emot. 1998; 12: 737-753
        • Bradley B.P.
        • Mogg K.
        • Millar N.
        • Bonham-Carter C.
        • Fergusson E.
        • Jenkins J.
        • Parr M.
        Attentional biases for emotional faces.
        Cogn Emot. 1997; 11: 25-42
        • Bradley M.M.
        • Lang P.J.
        Measuring emotion: The self-assessment manikin and the semantic differential.
        J Behav Ther Exp Psychiatry. 1994; 25: 49-59
        • Bradley M.M.
        • Silakowski T.
        • Lang P.J.
        Fear of pain and defensive activation.
        Pain. 2008; 137: 156-163
        • Cohen J.
        Eta- squared and partial eta-squared in fixed factor ANOVA designs.
        Educ Psychol Meas. 1973; 33: 107-112
        • Cornwell B.R.
        • Johnson L.
        • Berardi L.
        • Grillon C.
        Anticipation of public speaking in virtual reality reveals a relationship between trait social anxiety and startle reactivity.
        Biol Psychiatry. 2006; 59: 664-666
        • Crombez G.
        • Eccleston C.
        • Van Damme S.
        • Vlaeyen J.W.S.
        • Karoly P.
        Fear-avoidance model of chronic pain: The next generation.
        Clin J Pain. 2012; 28: 475-483
        • Crombez G.
        • Vlaeyen J.W.
        • Heuts P.H.T.
        • Lysens R.
        Pain-related fear is more disabling than pain itself: Evidence on the role of pain-related fear in chronic back pain disability.
        Pain. 1999; 80: 329-339
        • Fanselow M.S.
        Signaled shock-free periods and preference for signaled shock.
        J Exp Psychol Anim Behav Process. 1980; 6: 65-80
        • George S.Z.
        • Dannecker E.A.
        • Robinson M.E.
        Fear of pain, not pain catastrophizing, predicts acute pain intensity, but neither factor predicts tolerance or blood pressure reactivity: An experimental investigation in pain-free individuals.
        Eur J Pain. 2006; 10: 457-465
        • George S.Z.
        • Hirsh A.T.
        Psychologic influence on experimental pain sensitivity and clinical pain intensity for patients with shoulder pain.
        J Pain. 2009; 10: 293-299
        • Gheldof E.L.M.
        • Crombez G.
        • Van den Bussche E.
        • Vinck J.
        • Van Nieuwenhuyse A.
        • Moens G.
        • Mairiaux P.
        • Vlaeyen J.W.S.
        Pain-related fear predicts disability, but not pain severity: A path analytic approach of the fear-avoidance model.
        Eur J Pain. 2010; 14: 870.e1-870.e9
        • Gray K.
        • Wegner D.M.
        The sting of intentional pain.
        Psychol Sci. 2008; 19: 1260-1262
        • Green M.J.
        • Phillips M.L.
        Social threat perception and the evolution of paranoia.
        Neurosci Biobehav Rev. 2004; 28: 333-342
        • Greenhouse S.W.
        • Geisser S.
        On methods in the analysis of profile data.
        Psychometrika. 1959; 24: 95-112
        • Grillon C.
        Startle reactivity and anxiety disorders: Aversive conditioning, context, and neurobiology.
        Biol Psychiatry. 2002; 52: 958-975
        • Grillon C.
        • Davis M.
        Fear-potentiated startle conditioning in humans: Explicit and contextual cue conditioning following paired versus unpaired training.
        Psychophysiology. 1997; 34: 451-458
        • Kiernan M.
        • Westbrook R.
        Effects of exposure to a to-be-shocked environment upon the rat's freezing response: Evidence for facilitation, latent inhibition, and perceptual learning.
        Q J Exp Psychol B. 1993; 46: 271-288
        • Krahé C.
        • Springer A.
        • Weinman J.A.
        • Fotopoulou A.
        The social modulation of pain: Others as predictive signals of salience—a systematic review.
        Front Hum Neurosci. 2013; 7: 386
        • Leeuw M.
        • Goossens M.E.
        • Linton S.J.
        • Crombez G.
        • Boersma K.
        • Vlaeyen J.W.S.
        The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence.
        J Behav Med. 2007; 30: 77-94
        • Meulders A.
        • Vandebroek N.
        • Vervliet B.
        • Vlaeyen J.W.S.
        Generalization gradients in cued and contextual pain-related fear: An experimental study in healthy participants.
        Front Hum Neurosci. 2013; 7: 345
        • Meulders A.
        • Vansteenwegen D.
        • Vlaeyen J.W.S.
        The acquisition of fear of movement-related pain and associative learning: A novel pain-relevant human fear conditioning paradigm.
        Pain. 2011; 152: 2460-2469
        • Meulders A.
        • Vansteenwegen D.
        • Vlaeyen J.W.S.
        Women, but not men, report increasingly more pain during repeated (un)predictable painful electrocutaneous stimulation: Evidence for mediation by fear of pain.
        Pain. 2012; 153: 1030-1041
        • Meulders A.
        • Vervliet B.
        • Fonteyne R.
        • Baeyens F.
        • Hermans D.
        • Vansteenwegen D.
        Preexposure to (un)predictable shock modulates discriminative fear learning between cue and context: An investigation of the interaction between fear and anxiety.
        Int J Psychophysiol. 2012; 84: 180-187
        • Meulders A.
        • Vlaeyen J.W.S.
        Reduction of fear of movement-related pain and pain-related anxiety: An associative learning approach using a voluntary movement paradigm.
        Pain. 2012; 153: 1504-1513
        • Meulders A.
        • Vlaeyen J.W.S.
        Mere intention to perform painful movements elicits fear of movement-related pain: An experimental study on fear acquisition beyond actual movements.
        J Pain. 2013; 14: 412-423
        • Meulders A.
        • Vlaeyen J.W.S.
        The acquisition and generalization of cued and contextual pain-related fear: An experimental study using a voluntary movement paradigm.
        Pain. 2013; 154: 272-282
        • Mineka S.
        • Gino A.
        Dissociation between conditioned emotional response and extended avoidance performance.
        Learn Motiv. 1980; 11: 476-502
        • Moseley G.L.
        • Arntz A.
        The context of a noxious stimulus affects the pain it evokes.
        Pain. 2007; 133: 64-71
        • Nakagawa S.
        • Cuthill I.C.
        Effect size, confidence interval and statistical significance: A practical guide for biologists.
        Biol Rev Camb Philos Soc. 2007; 82: 591-605
        • Öhman A.
        Stimulus Prepotency and Fear Learning: Data and Theory.
        in: Birbaumer N. Öhman A. The Structure of Emotion. Hogrefe & Huber, Seattle, WA1993: 218-239
        • Öhman A.
        • Mineka S.
        Fears, phobias, and preparedness: Toward an evolved module of fear and fear learning.
        Psychol Rev. 2001; 108: 483-522
        • Peeters P.A.
        • Vlaeyen J.W.S.
        Feeling more pain, yet showing less: The influence of social threat on pain.
        J Pain. 2011; 12: 1255-1261
        • Pérez-Edgar K.
        • Reeb-Sutherland B.C.
        • McDermott J.M.
        • White L.K.
        • Henderson H.A.
        • Degnan K.A.
        • Hane A.A.
        • Pine D.S.
        • Fox N.A.
        Attention biases to threat link behavioral inhibition to social withdrawal over time in very young children.
        J Abnorm Child Psychol. 2011; 39: 885-895
        • Pissiota A.
        • Frans O.
        • Michelgard A.
        • Appel L.
        • Langstrom B.
        • Flaten M.A.
        • Fredrikson M.
        Amygdala and anterior cingulate cortex activation during affective startle modulation: A PET study of fear.
        Eur J Neurosci. 2003; 18: 1325-1331
        • Rhudy J.L.
        • Meagher M.W.
        Fear and anxiety: Divergent effects on human pain thresholds.
        Pain. 2000; 84: 65-75
        • Roelofs K.
        • Hagenaars M.A.
        • Stins J.
        Facing freeze: Social threat induces bodily freeze in humans.
        Psychol Sci. 2010; 21: 1575-1581
        • Sandrini G.
        • Serrao M.
        • Rossi P.
        • Romaniello A.
        • Cruccu G.
        • Willer J.C.
        The lower limb flexion reflex in humans.
        Prog Neurobiol. 2005; 77: 353-395
        • Seligman M.E.P.
        Phobias and preparedness.
        Behav Ther. 1971; 2: 307-320
        • Sigmundi R.A.
        • Bouton M.E.
        • Bolles R.C.
        Conditioned freezing in the rat as a function of shock intensity and CS modality.
        Bull Psychon Soc. 2013; 15: 254-256
        • Soeter M.
        • Kindt M.
        Dissociating response systems: Erasing fear from memory.
        Neurobiol Learn Mem. 2010; 94: 30-41
        • Spruyt A.
        • Clarysse J.
        • Vansteenwegen D.
        • Baeyens F.
        • Hermans D.
        Affect 4.0: A free software package for implementing psychological and psychophysiological experiments.
        Exp Psychol. 2010; 57: 36-45
        • Sullivan M.J.L.
        • Adams H.
        • Horan S.
        • Maher D.
        • Boland D.
        • Gross R.
        The role of perceived injustice in the experience of chronic pain and disability: Scale development and validation.
        J Occup Rehabil. 2008; 18: 249-261
        • Tottenham N.
        • Tanaka J.W.
        • Leon A.C.
        • McCarry T.
        • Nurse M.
        • Hare T.A.
        • Marcus D.J.
        • Westerlund A.
        • Casey B.J.
        • Nelson C.
        The NimStim set of facial expressions: Judgments from untrained research participants.
        Psychiatry Res. 2009; 168: 242-249
        • Trost Z.
        • France C.R.
        • Sullivan M.J.
        • Thomas J.S.
        Pain-related fear predicts reduced spinal motion following experimental back injury.
        Pain. 2012; 153: 1015-1021
        • Trost Z.
        • France C.R.
        • Thomas J.S.
        Pain-related fear and avoidance of physical exertion following delayed-onset muscle soreness.
        Pain. 2011; 152: 1540-1547
        • Vansteenwegen D.
        • Iberico C.
        • Vervliet B.
        • Marescau V.
        • Hermans D.
        Contextual fear induced by unpredictability in a human fear conditioning preparation is related to the chronic expectation of a threatening US.
        Biol Psychol. 2008; 77: 39-46
        • Vlaeyen J.W.S.
        • De Jong J.R.
        • Onghena P.
        • Kerckhoffs-Hanssen M.
        • Kole-Snijders A.M.J.
        Can pain-related fear be reduced? The application of cognitive-behavioural exposure in vivo.
        Pain Res Manag. 2002; 7: 144-153
        • Vlaeyen J.W.S.
        • Hanssen M.
        • Goubert L.
        • Vervoort T.
        • Peters M.
        • van Breukelen G.
        • Sullivan M.J.L.
        • Morley S.
        Threat of pain influences social context effects on verbal pain report and facial expression.
        Behav Res Ther. 2009; 47: 774-782
        • Vlaeyen J.W.
        • Kole-Snijders A.M.
        • Boeren R.G.
        • van Eek H.
        Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance.
        Pain. 1995; 62: 363-372
        • Vlaeyen J.W.S.
        • Linton S.J.
        Fear-avoidance model of chronic musculoskeletal pain: 12 years on.
        Pain. 2012; 153: 1144-1157
        • Wiech K.
        • Tracey I.
        Pain, decisions, and actions: A motivational perspective.
        Front Neurosci. 2013; 7: 1-12
        • Wolke D.
        • Copeland W.E.
        • Angold A.
        • Costello E.J.
        Impact of bullying in childhood on adult health, wealth, crime, and social outcomes.
        Psychol Sci. 2013; 24: 1958-1970
        • Zale E.L.
        • Lange K.L.
        • Fields S.A.
        • Ditre J.W.
        The relation between pain-related fear and disability: A meta-analysis.
        J Pain. 2013; 14: 1019-1030