Investigating pain-related cognitive biases using ABIB-VR paradigm

This protocol has been registered and approved by the Ethical committee of Maastricht University (Number: OZL_249_20_02_2022_S1_A2). Pain theories propose cognitive biases (CB) to be pivotal in the development and maintenance of chronic pain (Pincus & Morley, 2001; Todd et al., 2015) and different cognitive biases interactively lead to poor pain outcomes (Pincus & Morley, 2001; Todd, Sharpe, Colagiuri, & Khatibi, 2016; Van Ryckeghem, Noel, Sharpe, Pincus, & Van Damme, 2019; Van Ryckeghem & Vervoort, 2016). In this context, pain research has extensively studied selective attention to pain threatening information (attention bias; AB), increased threat interpretation to ambiguous pain information (interpretation bias; IB), and preferential recall to pain related information or as more threatening than initially experienced (memory bias; MB) (Van Ryckeghem, Noel, Sharpe, Pincus, & Van Damme, 2019). There has been a number of studies investigating pain-related attention bias in the past two decades (Broadbent, Liossi, & Schoth, 2021; Crombez, Van Ryckeghem, Eccleston, & Van Damme, 2013; Jones et al., 2021; Todd, Van Ryckeghem, Sharpe, & Crombez, 2018) and recently also more interpretation bias (Schoth & Liossi, 2016). So far, there is no general agreement about the pain-related attention bias. A meta-analysis (Todd et al., 2018) showed that people suffering from chronic pain showed more pain-related attention bias compared with people in acute pain, anticipating pain, or healthy condition. However, two other related meta-analyses reported no pain status difference in attention bias toward pain information between people in chronic pain and healthy condition (Chan, Suen, Jackson, Vlaeyen, & Barry, 2020; Crombez et al., 2013). As for pain-related interpretation bias, meta-analysis study from Schoth and Liossi (2016) showed more interpretation bias toward ambiguous pain-related/illness-related information in patients with chronic pain compared to healthy people, though the number of studies is limited in this meta-analysis. Yet, despite these positive findings and many efforts in improving paradigms to measure cognitive biases, further dedications are still needed to enhance the theory-driven assessment of pain-related cognitive biases using ecological valid paradigms. By far, the majority of the related studies measured cognitive biases toward pain by means of computer tasks (e.g., dot-probe tasks) using response time or self-reported measures, and symbolic pain stimuli (e.g., words, pictures) were commonly used to characterize pain stimuli, which may lack validity to induce the real sensational pain feeling. On the other side, pain-related cognitive biases were usually measured in separate task paradigms, which may increase the dissimilarity from the lab setting to the actual pain-related events, considering those cognitive biases can happen at the same time. Thus, more efforts are needed to develop theory-driven assessments using innovative paradigms with higher ecological validity. Finally, early accounts on pain processing indicate that pain-related interpretation bias and attention bias may be strongly intertwined (Pincus & Morley, 2001), and more recent theories suggest that the impact of each bias in isolation may be different than their combined effect (Todd et al., 2015; Van Ryckeghem et al., 2019). As prior research suggested, endorsement of pain-related interpretation was significantly correlated with more attention bias toward sensory-pain words in healthy people (Schoth, Parry, & Liossi, 2018). However, such finding was not always consistent. A follow-up study further explored the interrelations between various pain-related cognitive biases, while no evidence supported a significant relation between these two biases, even though similar experimental stimuli and task paradigms were employed (Schoth, Beaney, Broadbent, Zhang, & Liossi, 2018). More recently a study also reported pain-related attention bias was not interrelated with interpretation bias towards bodily threat and social situations in adolescents with varying pain levels (Kavallari & Lau, 2022). To address these inadequacies, the current study aims to provide an initial test of a newly developed ABIB-VR paradigm for the assessment of pain-related attention bias and interpretation bias. The interrelation between pain-related cognitive biases (i.e., pain-related attention and interpretation bias) will also be investigated.