Where attention lies in pain

Pain undoubtedly grabs our attention. That is the point in fact, so that we can adopt a behaviour that seeks to protect the injured tissues and start to create the right conditions for healing and recovery. In the case of a new injury this is highly adaptive and useful, however in persisting pain the sensation continues to ask for our attention in the same way despite the fact that the pain is not an accurate indicator of a tissue or structural problem – see here.

Recently a study found that those who with a large bias of attention towards predictive pain cues or who experienced higher levels of initial pain, did not find that distraction worked so effectively. This is very interesting and relevant because it allows us to identify those in pain who may not benefit from distraction methods and helps us to understand why some patients may describe situations when they attempted to move their focus away from the pain without success of any note.

Pain. 2012 Dec;153(12):2345-51

Attentional bias towards pain-related information diminishes the efficacy of distraction.

Van Ryckeghem DM, Crombez G, Van Hulle L, Van Damme S.


Distraction is a strategy that is commonly used to cope with pain. Results concerning the efficacy of distraction from both experimental and clinical studies are variable, however, and indicate that its efficacy may depend on particular circumstances. Several models propose that distraction may be less effective for people who display a large attentional bias towards pain-related information. This hypothesis was tested in an experimental context with 53 pain-free volunteers. First, attentional bias towards cues signalling the occurrence of pain (electrocutaneous stimuli) and towards words describing the sensory experience of this painful stimulus was independently assessed by means of 2 behavioural paradigms (respectively, spatial cueing task and dot-probe task). This was followed by a subsequent distraction task during which the efficacy of distraction, by directing attention away from the electrocutaneous stimuli, was tested. In addition, state-trait anxiety, catastrophic thinking, and initial pain intensity were measured. Results indicated that people who display a large attentional bias towards predictive cues of pain or who initially experience the pain as more painful benefit less from distraction on a subsequent test. No effects were found between attentional bias towards pain words, state-trait anxiety, catastrophic thinking, and the efficacy of distraction. Current findings suggest that distraction should not be used as a ‘one size fits all’ method to control pain, but only under more specific conditions.

There have been many studies looking at attentional bias and the effect upon the experience of pain. We can only be consciously aware of a certain amount of the mass of sensory stimuli, the brain effectively filtering data and processing what is relevant and important right now, perhaps via a salient network.  If there is a possibility that our body is in danger, this can be enough for the emergence of pain from the perceived area in question. Regular readers will be aware that despite the fact that we feel pain in the body, the underpinning activity is within the brain involving many different regions that are non-specific for pain. This is a reason why the range of cues that can trigger a protective response (i.e./ pain, altered movement, immune and endocrine activity) such as movement, perception of movement, thinking of movement, watching others move, stress, fatigue and emotional state to name but a few.

To attend to pain repeatedly as well as other signals from the body is known as hypervigilance. This can be accompanied by catastrophising, that is the negative interpretation of the signal usually followed by a more defensive behaviour. This is a problem if it persists as usually the behaviours lead to inactivity alongside the fear of movement, reducing quality of life and impacting in many ways including often enhancing the sense of pain. Tackling this aspect of the pain problem is vital in persisting states. Developing understanding of pain, the influences upon pain and having a range of strategies to work with the pain by thinking about how we can change the brain’s activity is important. Pain is not static. It is changeable and to be able to alter one’ experience is both positive and empowering, creating the self-efficacy and resilience needed to improve performance and deal with the pain to move forward.

Several other recent studies:

Pain. 2013 Mar;154(3):468-75.

The predictive value of attentional bias towards pain-related information in chronic pain patients: a diary study.

Van Ryckeghem DM, Crombez G, Goubert L, De Houwer J, Onraedt T, Van Damme S.


Theoretical accounts of chronic pain hypothesize that attentional bias towards pain-related information is a maintaining or exacerbating factor, fuelling further pain, disability, and distress. However, empirical research testing this idea is currently lacking. In the present study, we investigated whether attentional bias towards pain-related information predicts daily pain-related outcomes in a sample of chronic pain patients (n=69; M(age)=49.64 years; 46 females). During an initial laboratory session, attentional bias to pain-related information was assessed using a modified spatial cueing task. In advance, patients completed a number of self-report measures assessing current pain intensity, current disability, and pain duration. Subsequently, daily pain outcomes (self-reported pain severity, disability, avoidance behaviour, and distractibility) were measured for 2 weeks by means of an electronic diary. Results indicated that, although an attentional bias towards pain-related information was associated with the current level of disability and pain severity, it had no additional value above control variables in predicting daily pain severity, avoidance, distractibility, and disability. Attentional bias towards pain-related information did, however, moderate the relationship between daily pain severity and both daily disability and distractibility, indicating that, particularly in those patients with a strong attentional bias, increases in pain were associated with increased disability and distractibility. The use of interventions that diminish attentional bias may therefore be helpful to reduce daily disability and the level of distraction from current tasks despite the presence of pain in chronic pain patients.


Eur J Pain. 2013 Mar;17(3):402-11.

Keeping pain out of your mind: the role of attentional set in pain.

Van Ryckeghem DM, Crombez G, Eccleston C, Legrain V, Van Damme S.



The involuntary capture of attention by pain may, to some extent, be controlled by psychological variables. In this paper, we investigated the effect of attentional set (i.e., the collection of task-related features that a person is monitoring in order to successfully pursue a goal) on pain.


Two experiments are reported in which the task relevance of the modality and spatial location of a target stimulus was manipulated. In both experiments, somatosensory and auditory stimuli were presented on each trial. In experiment 1, 29 participants were cued on each trial to localize either a somatosensory or an auditory target. In experiment 2, 37 participants were cued on each trial to identify either a somatosensory or an auditory target at a particular location.


In experiment 1, self-reported pain intensity and unpleasantness were reduced when participants had to localize the auditory target. The location of the painful stimulus relative to the location of the auditory target did not affect pain. In experiment 2, again, pain intensity and unpleasantness ratings were reduced when participants identified the auditory target. Now, the location of the painful stimulus relative to the location of the auditory target moderated the effect. Pain intensity was less when the painful stimulus was at a different location than the auditory target.


Results are discussed in terms of the attentional set hypothesis, and we argue that the effectiveness of distraction tasks depends on the degree to which the task-relevant features of the distraction task are distinct from pain-related features.


For further information about our treatment & training programmes for persisting pain, chronic pain and injury, and our specialist Complex Regional Pain Syndrome Clinics, please call us on 07932 689081 or visit the clinic website here.


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