Mindfulness and Acute Experimental Pain Among Adolescents
Mindfulness and Acute Experimental Pain Among Adolescents
Objective. Attention-based coping strategies for pain are widely used in pediatric populations. The purpose of this study was to test a novel mindful attention manipulation on adolescent's experimental pain responses. Furthermore, the relationship between state mindfulness and experimental pain was examined.
Methods. A total of 198 adolescents were randomly assigned to a mindful attention manipulation or control group prior to an experimental pain task. Participants completed measures of state mindfulness immediately prior to the pain task, and situational catastrophizing and pain intensity following the task.
Results. Overall the manipulation had no effect on pain. Secondary analysis showed that meditation experience moderated the effect of the manipulation. State mindfulness predicted pain outcomes, with reductions in situational catastrophizing mediating this relationship.
Conclusions. The mindful attention manipulation was effective among adolescents with a regular meditation practice. State mindfulness was related to ameliorated pain responses, and these effects were mediated by reduced catastrophizing.
Pain is defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage" (International Association for the Study of Pain, 1979, p. 249). Acute pain due to illness, injury, and medical procedures as well as everyday bumps and bruises are a frequent occurrence among adolescents and children (Cummings, Reid, Finley, McGrath, & Ritchie, 1996; Perquin et al., 2000). Pain is influenced by more than the extent of physical injury, and the way in which young people cope with the sensory and emotional aspects of pain significantly impacts their pain experience (Asmundson, Noel, Petter, & Parkerson, 2012). Attention-based coping strategies are widely used in the management of both recurrent and acute pain in pediatric populations (Noel, Petter, Parker, & Chambers, 2012; Uman, Chambers, McGrath, & Kisely, 2008). Coping strategies designed to take attention away from painful stimuli (e.g., distraction) have a strong evidence base for acute pain (Uman et al., 2008). It is hypothesized that these manipulations are effective because attending to an alternative stimulus limits attentional resources available to process pain (Johnson, 2005). However, it has been theorized that when pain is viewed as highly threatening it may place such a strong demand on attention that the effects of distraction will be reduced (Eccleston & Crombez, 1999). Evidence with pediatric populations has supported the claim that the effects of distraction are reduced when pain is viewed as highly threatening. In particular, the tendency to catastrophize about pain appears to reduce the use and effectiveness of distraction among children and adolescents during acute pain, and attempts to use distraction may actually worsen pain (Verhoeven, Goubert, Jaaniste, Van Ryckeghem, & Crombez, 2011). Pain catastrophizing refers to the tendency to magnify the threat value of pain, to feel helpless in the face of pain, and to ruminate about pain, and this variable plays a central role in psychological models of pediatric chronic pain (e.g., Asmundson et al., 2012). Because painful sensations may place such a strong demand on attentional resources, researchers have argued that coping strategies which direct attention towards pain in an adaptive manner may be more effective for young people who are high in catastrophizing (Verhoeven et al., 2011).
There is evidence among adults that directing attention towards painful stimuli mindfully may offer benefit in both acute (Zeidan, Gordon, Merchant, & Goolkasian, 2010) and chronic pain (Chiesa & Serretti, 2011) contexts. Mindfulness involves paying attention, on purpose, to present moment experience, in a nonjudgmental and accepting manner (Kabat-Zinn, 1996). This nonjudgmental focus on present-moment experience appears to be a potentially fruitful avenue in helping adolescents attend to pain adaptively. Mindfulness combines aspects of attention-based coping strategies that direct attention towards pain, such as sensory-focused (e.g., Fanurik, Zeltzer, Roberts, & Blount, 1993; Piira, Hayes, Goodenough, & von Baeyer, 2006) and acceptance-based (Hayes et al., 1999) manipulations which have been found to ameliorate acute pain. Standard mindfulness-based interventions are 8 weeks in duration and place a strong emphasis on daily meditation practice (Carmody & Baer, 2009), requiring more time and resources than the brief attention-based coping strategies such as distraction.
Shortened mindfulness interventions for acute pain appear beneficial among adults. For example, Zeidan and colleagues (2010) found that three 20-min sessions of mindfulness training decreased pain intensity during an experimental pain task. Although employing shorter than typical mindfulness interventions, this study still required participants to attend multiple training sessions, requiring more resources than brief distraction-based interventions. It is also important to note that findings with adults may not generalize to youth based on important differences in the development of attentional, cognitive, and emotional regulation abilities (Semple, Lee, & Miller, 2006). Most importantly, meta-cognitive and self-regulation skills which are central to the use of mindfulness continue to develop throughout the adolescent years (Dahl, 2004). Indeed, many of the brain regions hypothesized to be involved in the application of mindfulness to pain such as the the dorso-lateral prefrontal cortex and the orbitofrontal cortex (Zeidan, Grant, Brown, McHaffie, and Coghill, 2012) are among the last brain regions to fully develop (Gogtay et al., 2004). Encouragingly, standard length mindfulness-based interventions have been found to be effective among adolescent psychiatric populations (Biegel, Brown, Shapiro, & Schubert, 2009). In addition, a recent study of children aged 10–14 years found that a set of mindful attention instructions administered prior to and during an experimental pain task was successful in directing attention towards pain, and no significant differences were found between this manipulation and a more traditional distraction-based manipulation (Petter, Chambers, & Chorney, 2013). However, this study lacked a control group, and it remains unclear whether this type of manipulation is more effective than youth's typical coping responses. Furthermore, this previous study did not examine the potential role of meditation experience in moderating the impact of this type of mindfulness manipulation. This is a potentially important avenue of research given the belief within the field of mindfulness research that attending to unpleasant stimuli in a mindful manner is a skill that may need to be developed through a regular meditation practice (Kabat-Zinn, 2003).
The hypothesis that instructing adolescents to attend mindfully during a pain task will ameliorate pain responses is based on the assumption that a state of nonjudgmental present-moment awareness may buffer against secondary evaluations of physical sensations (i.e., catastrophizing) that increase pain severity (Campbell et al., 2010). On a theoretical level, a state of mindfulness appears antithetical to catastrophizing, which involves negative secondary processing of physical sensations as well as the individual's ability to tolerate those sensations. Evidence indicates that trait mindfulness (the tendency to be mindful over time) is associated with physical and psychological well-being among adolescents (Brown, West, Loverich, & Biegel, 2011; Greco, Baer, & Smith, 2011), and is a unique predictor of a number of outcomes in adult chronic pain populations (McCracken & Keogh, 2009), and that pain catastrophizing may mediate the relationship between mindfulness and chronic pain outcomes (Cassidy, Atherton, Robertson, Walsh, & Gillett, 2012). However, to-date the relationship between state mindfulness, catastrophizing, and pain has not been examined in the acute pain context. Based on theoretical work and findings related to chronic pain, it appears that state mindfulness may be associated with reductions in catastrophic thinking during acute pain, and through this relationship, may be associated with lower levels of perceived pain intensity and increased pain tolerance.
The primary purpose of this project was to examine the effects of a brief mindful attention manipulation on experimental pain among adolescents. The manipulation was hypothesized to result in increased levels of state mindfulness, decreased catastrophic thoughts during the decreased pain intensity and increased tolerance (Hypothesis 1). Furthermore, it was hypothesized that trait levels of pain catastrophizing would moderate the effects of this manipulation on the outcomes of pain intensity and pain tolerance, such that the manipulation would be more effective among adolescents higher in trait pain catastrophizing (Hypothesis 2). This prediction is based on theoretical and experimental studies which have hypothesized that individuals high in catastrophizing may find directing attention away from pain to be difficult and thus would benefit from manipulations which direct attention towards pain (Eccleston & Crombez, 1999; Verhoeven et al., 2011). Secondary analyses examining the moderating role of previous meditation experience were also conducted given evidence with adult populations that previous meditation experience may moderate the ability to attend mindfully to pain (Grant & Rainville, 2009), Specifically, it was hypothesized that the intervention would be more effective among adolescents with a regular meditation practice such that those who received the mindful attention manipulation would reported decreased pain intensity and increased pain tolerance (Hypothesis 3). Additionally, this study examined the relationship between state mindfulness and experimental pain outcomes. Based on theory and findings with chronic pain, it was hypothesized that higher state mindfulness would result in lowered pain intensity and increased pain tolerance, and that these relationships would be mediated by reductions in catastrophic thinking during the pain task (Hypothesis 4).
Abstract and Introduction
Abstract
Objective. Attention-based coping strategies for pain are widely used in pediatric populations. The purpose of this study was to test a novel mindful attention manipulation on adolescent's experimental pain responses. Furthermore, the relationship between state mindfulness and experimental pain was examined.
Methods. A total of 198 adolescents were randomly assigned to a mindful attention manipulation or control group prior to an experimental pain task. Participants completed measures of state mindfulness immediately prior to the pain task, and situational catastrophizing and pain intensity following the task.
Results. Overall the manipulation had no effect on pain. Secondary analysis showed that meditation experience moderated the effect of the manipulation. State mindfulness predicted pain outcomes, with reductions in situational catastrophizing mediating this relationship.
Conclusions. The mindful attention manipulation was effective among adolescents with a regular meditation practice. State mindfulness was related to ameliorated pain responses, and these effects were mediated by reduced catastrophizing.
Introduction
Pain is defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage" (International Association for the Study of Pain, 1979, p. 249). Acute pain due to illness, injury, and medical procedures as well as everyday bumps and bruises are a frequent occurrence among adolescents and children (Cummings, Reid, Finley, McGrath, & Ritchie, 1996; Perquin et al., 2000). Pain is influenced by more than the extent of physical injury, and the way in which young people cope with the sensory and emotional aspects of pain significantly impacts their pain experience (Asmundson, Noel, Petter, & Parkerson, 2012). Attention-based coping strategies are widely used in the management of both recurrent and acute pain in pediatric populations (Noel, Petter, Parker, & Chambers, 2012; Uman, Chambers, McGrath, & Kisely, 2008). Coping strategies designed to take attention away from painful stimuli (e.g., distraction) have a strong evidence base for acute pain (Uman et al., 2008). It is hypothesized that these manipulations are effective because attending to an alternative stimulus limits attentional resources available to process pain (Johnson, 2005). However, it has been theorized that when pain is viewed as highly threatening it may place such a strong demand on attention that the effects of distraction will be reduced (Eccleston & Crombez, 1999). Evidence with pediatric populations has supported the claim that the effects of distraction are reduced when pain is viewed as highly threatening. In particular, the tendency to catastrophize about pain appears to reduce the use and effectiveness of distraction among children and adolescents during acute pain, and attempts to use distraction may actually worsen pain (Verhoeven, Goubert, Jaaniste, Van Ryckeghem, & Crombez, 2011). Pain catastrophizing refers to the tendency to magnify the threat value of pain, to feel helpless in the face of pain, and to ruminate about pain, and this variable plays a central role in psychological models of pediatric chronic pain (e.g., Asmundson et al., 2012). Because painful sensations may place such a strong demand on attentional resources, researchers have argued that coping strategies which direct attention towards pain in an adaptive manner may be more effective for young people who are high in catastrophizing (Verhoeven et al., 2011).
There is evidence among adults that directing attention towards painful stimuli mindfully may offer benefit in both acute (Zeidan, Gordon, Merchant, & Goolkasian, 2010) and chronic pain (Chiesa & Serretti, 2011) contexts. Mindfulness involves paying attention, on purpose, to present moment experience, in a nonjudgmental and accepting manner (Kabat-Zinn, 1996). This nonjudgmental focus on present-moment experience appears to be a potentially fruitful avenue in helping adolescents attend to pain adaptively. Mindfulness combines aspects of attention-based coping strategies that direct attention towards pain, such as sensory-focused (e.g., Fanurik, Zeltzer, Roberts, & Blount, 1993; Piira, Hayes, Goodenough, & von Baeyer, 2006) and acceptance-based (Hayes et al., 1999) manipulations which have been found to ameliorate acute pain. Standard mindfulness-based interventions are 8 weeks in duration and place a strong emphasis on daily meditation practice (Carmody & Baer, 2009), requiring more time and resources than the brief attention-based coping strategies such as distraction.
Shortened mindfulness interventions for acute pain appear beneficial among adults. For example, Zeidan and colleagues (2010) found that three 20-min sessions of mindfulness training decreased pain intensity during an experimental pain task. Although employing shorter than typical mindfulness interventions, this study still required participants to attend multiple training sessions, requiring more resources than brief distraction-based interventions. It is also important to note that findings with adults may not generalize to youth based on important differences in the development of attentional, cognitive, and emotional regulation abilities (Semple, Lee, & Miller, 2006). Most importantly, meta-cognitive and self-regulation skills which are central to the use of mindfulness continue to develop throughout the adolescent years (Dahl, 2004). Indeed, many of the brain regions hypothesized to be involved in the application of mindfulness to pain such as the the dorso-lateral prefrontal cortex and the orbitofrontal cortex (Zeidan, Grant, Brown, McHaffie, and Coghill, 2012) are among the last brain regions to fully develop (Gogtay et al., 2004). Encouragingly, standard length mindfulness-based interventions have been found to be effective among adolescent psychiatric populations (Biegel, Brown, Shapiro, & Schubert, 2009). In addition, a recent study of children aged 10–14 years found that a set of mindful attention instructions administered prior to and during an experimental pain task was successful in directing attention towards pain, and no significant differences were found between this manipulation and a more traditional distraction-based manipulation (Petter, Chambers, & Chorney, 2013). However, this study lacked a control group, and it remains unclear whether this type of manipulation is more effective than youth's typical coping responses. Furthermore, this previous study did not examine the potential role of meditation experience in moderating the impact of this type of mindfulness manipulation. This is a potentially important avenue of research given the belief within the field of mindfulness research that attending to unpleasant stimuli in a mindful manner is a skill that may need to be developed through a regular meditation practice (Kabat-Zinn, 2003).
The hypothesis that instructing adolescents to attend mindfully during a pain task will ameliorate pain responses is based on the assumption that a state of nonjudgmental present-moment awareness may buffer against secondary evaluations of physical sensations (i.e., catastrophizing) that increase pain severity (Campbell et al., 2010). On a theoretical level, a state of mindfulness appears antithetical to catastrophizing, which involves negative secondary processing of physical sensations as well as the individual's ability to tolerate those sensations. Evidence indicates that trait mindfulness (the tendency to be mindful over time) is associated with physical and psychological well-being among adolescents (Brown, West, Loverich, & Biegel, 2011; Greco, Baer, & Smith, 2011), and is a unique predictor of a number of outcomes in adult chronic pain populations (McCracken & Keogh, 2009), and that pain catastrophizing may mediate the relationship between mindfulness and chronic pain outcomes (Cassidy, Atherton, Robertson, Walsh, & Gillett, 2012). However, to-date the relationship between state mindfulness, catastrophizing, and pain has not been examined in the acute pain context. Based on theoretical work and findings related to chronic pain, it appears that state mindfulness may be associated with reductions in catastrophic thinking during acute pain, and through this relationship, may be associated with lower levels of perceived pain intensity and increased pain tolerance.
The primary purpose of this project was to examine the effects of a brief mindful attention manipulation on experimental pain among adolescents. The manipulation was hypothesized to result in increased levels of state mindfulness, decreased catastrophic thoughts during the decreased pain intensity and increased tolerance (Hypothesis 1). Furthermore, it was hypothesized that trait levels of pain catastrophizing would moderate the effects of this manipulation on the outcomes of pain intensity and pain tolerance, such that the manipulation would be more effective among adolescents higher in trait pain catastrophizing (Hypothesis 2). This prediction is based on theoretical and experimental studies which have hypothesized that individuals high in catastrophizing may find directing attention away from pain to be difficult and thus would benefit from manipulations which direct attention towards pain (Eccleston & Crombez, 1999; Verhoeven et al., 2011). Secondary analyses examining the moderating role of previous meditation experience were also conducted given evidence with adult populations that previous meditation experience may moderate the ability to attend mindfully to pain (Grant & Rainville, 2009), Specifically, it was hypothesized that the intervention would be more effective among adolescents with a regular meditation practice such that those who received the mindful attention manipulation would reported decreased pain intensity and increased pain tolerance (Hypothesis 3). Additionally, this study examined the relationship between state mindfulness and experimental pain outcomes. Based on theory and findings with chronic pain, it was hypothesized that higher state mindfulness would result in lowered pain intensity and increased pain tolerance, and that these relationships would be mediated by reductions in catastrophic thinking during the pain task (Hypothesis 4).
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