Highlights
- •Classical conditioning processes may contribute to chronic pain-related disability.
- •Seven studies investigated if chronic pain relates to altered classical conditioning.
- •Chronic pain patients tend to show less selective pain expectancy and fear learning.
- •Classical conditioning deficits may predispose or maintain chronic pain disability.
Abstract
Prominent clinical models of chronic pain propose a fundamental role of classical
conditioning in the development of pain-related disability. If classical conditioning
is key to this process, then people with chronic pain may show a different response
to pain-related conditioned stimuli than healthy control subjects. We set out to determine
whether this is the case by undertaking a comprehensive and systematic review of the
literature. To identify studies comparing classical conditioning between people with
chronic pain and healthy control subjects, the databases MEDLINE, PsychINFO, PsychARTICLES,
Scopus, and CINAHL were searched using key words and medical subject headings consistent
with ‘classical conditioning’ and ‘pain.’ Articles were included when: 1) pain-free
control and chronic pain groups were included, and 2) a differential classical conditioning
design was used. The systematic search revealed 7 studies investigating differences
in classical conditioning between people with chronic pain and healthy control participants.
The included studies involved a total of 129 people with chronic pain (fibromyalgia
syndrome, spinal pain, hand pain, irritable bowel syndrome), and 104 healthy control
participants. Outcomes included indices of pain-related conditioning such as unconditioned
stimulus (US) expectancy and contingency awareness, self-report and physiological
measures of pain-related fear, evaluative judgements of conditioned stimulus pleasantness,
and muscular and cortical responses. Because of variability in outcomes, meta-analyses
included a maximum of 4 studies. People with chronic pain tended to show reduced differential
learning and flatter generalization gradients with respect to US expectancy and fear-potentiated
eyeblink startle responses. Some studies showed a propensity for greater muscular
responses and perceptions of unpleasantness in response to pain-associated cues, relative
to control cues.
Perspective
The review revealed preliminary evidence that people with chronic pain may exhibit
less differential US expectancy and fear learning. This characteristic may contribute
to widespread fear-avoidance behavior. The assumption that altered classical conditioning
may be a predisposing or maintaining factor for chronic pain remains to be verified.
Key words
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Article info
Publication history
Published online: April 03, 2017
Footnotes
A.M. is a postdoctoral researcher of the Research Foundation Flanders (FWO-Vlaanderen), Belgium, (grant ID: 12E3714N). G.L.M. is supported by a National Health and Medical Research Council Senior Research Fellowship. This work is supported by National Health and Medical Research Council project grant ID 1047137.
The authors acknowledge that 3 of the included articles were led by coauthor A.M. and that this presents a potential conflict. A.M. was not involved in the search/inclusion process, and was not involved in assessing risk of bias of her own work. The authors have no further conflicts of interest to declare.
Supplementary data accompanying this article are available online at www.jpain.org and www.sciencedirect.com.
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© 2017 by the American Pain Society
