A Contextual Analysis of Attention to Chronic Pain: What the Patient Does With Their Pain Might Be More Important Than Their Awareness or Vigilance Alone

Published:September 19, 2006DOI:


      It is often believed that to feel greater pain is to experience greater effects of that pain, and that attention and awareness represent the transmission mechanism in this relationship. By implication, it is assumed that if attention and awareness can be lessened, the effects of pain will likewise reduce. Despite conceptual work and data suggesting more complex processes might indeed be in place, these long-standing and intuitively appealing ideas remain, either explicitly or implicitly, in both research and clinical applications. The purpose of this study was to compare the role of attentional processes in chronic pain with a process that is more contextual, functional, and behavior-focused, namely, acceptance. The hypothesis tested is whether it is more important to understand the amount of contact an individual has with pain, in this case awareness and vigilance to pain, or the degree of influence on behavior brought with that contact, in this case acceptance. Data from 227 patients seeking treatment for chronic pain were examined. Results from correlation analyses showed that acceptance scores achieved stronger correlations than scores for the attention variables with measures of cognitive, emotional, social, and physical functioning. When acceptance of pain was taken into account in multiple regression analyses, scores from the attention measures accounted for little or no variance in measures of patient functioning. The value of various mental, mechanical, behavior-focused, and contextual models of attention in chronic pain is discussed.


      Attention, awareness, and vigilance appear immediately applicable for understanding chronic pain. These processes, however, might be incomplete in accounting for pain-related suffering and disability. Acceptance is proposed as a process that expands the framework of attention to include varying cognitive, emotional, and social influences exerted by pain on patient behavior.

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        • Baer R.A.
        Mindfulness training as a clinical intervention: A conceptual and empirical review.
        Clin Psychol Res Pract. 2003; 10: 125-143
        • Beck A.T.
        • Ward C.H.
        • Mendelson M.
        • Mock J.
        • Erbaugh J.
        An inventory for measuring depression.
        Arch Gen Psychiatry. 1961; 4: 561-571
        • Bergner M.
        • Bobbitt R.A.
        • Carter W.B.
        • Gilson B.S.
        The Sickness Impact Profile: Development and final revision of a health status measure.
        Med Care. 1981; 19: 787-805
        • Cioffi D.
        • Holloway J.
        Delayed cost of suppressed pain.
        J Pers Soc Psychol. 1993; 64: 274-282
        • Crombez G.
        • Eccleston C.
        • Baeyens F.
        • Eelen P.
        The disruptive nature of pain: An experimental investigation.
        Behav Res Ther. 1996; 34: 911-918
        • Crombez G.
        • Eccleston C.
        • Baeyens F.
        • Van Houdenhove B.
        • Van den Broech A.
        Attention to chronic pain is dependent upon pain-related fear.
        J Psychsom Res. 1999; 47: 403-410
        • Crombez G.
        • Van Damme S.
        • Eccleston C.
        Hypervigilance to pain: An experimental and clinical analysis.
        Pain. 2005; 116: 4-7
        • Eccleston C.
        The attentional control of pain: Methodological and theoretical concerns.
        Pain. 1995; 63: 3-10
        • Eccleston C.
        • Crombez G.
        Pain demands attention: A cognitive-affective model of the interruptive function of pain.
        Psychol Bull. 1999; 125: 356-366
        • Goubert L.
        • Crombez G.
        • Eccleston C.
        • Devulder J.
        Distraction from chronic pain during pain-inducing activity is associated with greater post-activity pain.
        Pain. 2004; 110: 220-227
        • Hayes S.C.
        • Wilson K.G.
        • Strosahl K.
        • Gifford E.V.
        • Follette V.M.
        Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment.
        J Consult Clin Psychol. 1996; 64: 1152-1168
        • Hayes S.C.
        • Barnes-Holmes D.
        • Roche B.
        Relational Frame Theory: A Post-Skinnerian Account of Human Language and Cognition. Kluwer Academic/Plenum Publishers, New York, NY2001
        • Kabat-Zinn J.
        Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. Dell Publishing, New York, NY1990
        • Kabat-Zinn J.
        • Lipworth L.
        • Burney R.
        The clinical use of mindfulness meditation for self-regulation of chronic pain.
        J Behav Med. 1985; 8: 163-190
        • Lenz F.A.
        • Treede R.-D.
        Attention, novelty, and pain.
        Pain. 2002; 99: 1-3
        • Main C.J.
        The Modified Somatic Perception Questionnaire (MSPQ).
        J Psychosom Res. 1983; 27: 503-514
        • McCracken L.M.
        “Attention” to pain in persons with chronic pain: A behavioral approach.
        Behav Ther. 1997; 28: 271-284
        • McCracken L.M.
        Contextual cognitive-behavioral therapy for chronic pain, in Progress in Pain Research and Management, vol 33. IASP Press, Seattle, WA2005
        • McCracken L.M.
        Social context and acceptance of chronic pain: The role of solicitous and punishing responses.
        Pain. 2005; 113: 115-159
        • McCracken L.M.
        • Eccelston C.
        Coping or acceptance: What to do about chronic pain?.
        Pain. 2003; 105: 197-204
        • McCracken L.M.
        • Eccleston C.
        A prospective study of acceptance of pain and patient functioning with chronic pain.
        Pain. 2005; 118: 164-169
        • McCracken L.M.
        • Eccleston C.
        A comparison of the relative utility of coping and acceptance-based measures in a sample of chronic pain sufferers.
        Eur J Pain. 2006; 10: 23-29
        • McCracken L.M.
        • Vowles K.E.
        • Eccleston C.
        Acceptance of chronic pain: Component analysis and a revised assessment method.
        Pain. 2004; 107: 159-166
        • McCracken L.M.
        • Zayfert C.
        • Gross R.T.
        The Pain Anxiety Symptoms Scale: Development and validation of a scale to measure fear of pain.
        Pain. 1992; 50: 67-73
        • McDermid A.J.
        • Rollman G.B.
        • McCain G.A.
        Generalized hypervigilance in fibromyalgia: Evidence of perceptual amplification.
        Pain. 1996; 66: 133-144
        • Meng X.-L.
        • Rosenthal R.
        • Rubin D.B.
        Comparing correlated correlation coefficients.
        Psychol Bull. 1992; 111: 172-175
        • Morley S.
        • Shapiro D.A.
        • Biggs J.
        Developing a treatment manual for attention management in chronic pain.
        Cogn Behav Ther. 2004; 33: 1-11
        • Roelofs J.
        • McCracken L.
        • Peters M.L.
        • Crombez G.
        • van Brekelen G.
        • Vlaeyen J.W.S.
        Psychometric evaluation of the Pain Anxiety Symptoms Scale (PASS) in chronic pain patients.
        J Behav Med. 2004; 27: 167-183
        • Roelofs J.
        • Peters M.
        • McCracken L.M.
        • Vlaeyen J.W.S.
        The Pain Vigilance and Awareness Questionnaire (PVAQ): Psychometric evaluation in chronic pain patients.
        Pain. 2003; 101: 299-306
        • Rosenstiel A.K.
        • Keefe F.J.
        The use of coping strategies in chronic low back pain patients: Relationship to patient characteristics and current adjustment.
        Pain. 1983; 17: 33-44
        • Turk D.C.
        • Meichenbaum D.
        • Genest M.
        Pain and Behavioral Medicine: A Cognitive-Behavioral Perspective. The Guilford Press, New York, NY1983
        • Vancleef L.M.G.
        • Peters M.L.
        Pain catastrophzing, but not injury/illness sensitively or anxiety sensitivity, enhances attentional interference by pain.
        J Pain. 2006; 7: 23-30
        • Van Damme S.
        • Crombez G.
        • Eccleston C.
        Disengagement from pain: The role of catastrophic thinking about pain.
        Pain. 2004; 107: 70-76
        • Veldhuijzen D.S.
        • Kenemans J.L.
        • de Bruin C.M.
        • Olivier B.
        • Volkerts E.R.
        Pain and attention: Attentional disruption or distraction?.
        J Pain. 2006; 7: 11-20
        • Wade J.B.
        • Dougherty L.M.
        • Archer C.R.
        • Price D.D.
        Assessing the stages of pain processing: A multivariate analytic approach.
        Pain. 1996; 68: 157-167
        • Wegner D.M.
        • Schneider D.J.
        • Carter S.R.
        • White T.L.
        Paradoxical effects of thought suppression.
        J Pers Soc Psychol. 1987; 53: 5-13
        • Wiech K.
        • Seymour B.
        • Kalisch R.
        • Stephan K.E.
        • Koltzenburg M.
        • Driver J.
        • Dolan J.
        Modulation of pain processing in hyperalgesia by cognitive demand.
        NeuroImage. 2005; 27: 59-69