Chronic Pain and Emotional Stroop: Comparison
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Please note this is a comparison between Version 2 by Lindsay Dong and Version 1 by Lidia Amaro Díaz.

The emotional Stroop task is a valuable and suitable technique to measure the alterations in emotional and cerebral activation areas that characterize chronic pain conditions (i.e., FMS, migraine, CNP, CLBP, and TMDs). The emotional Stroop task proved to be a valid tool to assess emotional and pain processing in patients with chronic pain.

  • chronic pain
  • emotional Stroop task
  • brain regions
  • emotional regulation

1. Introduction

1.1. Emotional Stroop Task

The emotional Stroop task is a well-established paradigm based on the classic Stroop task [1,2,3][1][2][3]. The aim of this task is to evaluate the interference between emotional stimuli and cognitive processes [4]. There are two trial types in both tasks, i.e., incongruent (read the written word and de-code the semantic content; inhibition of an automated action) and congruent (focus on the color of the presented words; activation of a voluntary action) [5,6][5][6]. In the emotional Stroop task, the colors of words describing typical chronic pain symptoms (emotionally relevant words) must typically be specified, as well as non-disease-related words with positive, neutral, or negative connotations [2]. These words should be read as quickly as possible, ignoring the affective content of the stimuli presented [7]. This paradigm measures the cognitive interference that occurs when the processing of one stimulus (word) prevents simultaneous processing of a second stimulus (color) [1,8][1][8]. According to the emotional Stroop task, the magnitude of the interference effect depends on the extent to which the words are related to the individual’s emotional concerns [1].
The emotional Stroop task is a valuable tool to assess attentional bias in people with chronic pain, and can establish the extent to which patients preferentially attend to pain-related information over neutral or positive information [1,9,10,11][1][9][10][11]. Therefore, the pain hypervigilance hypothesis pertaining to chronic pain conditions can be investigated by the emotional Stroop task [2,11,12][2][11][12]. This hypothesis suggests that involuntary attention to pain-related information is relevant to the development of these disorders [2,11,12][2][11][12]. Different versions of the task have been applied.

1.2. Chronic Pain

Chronic pain is defined by the International Association for the Study of Pain (2020) as a pain condition that lasts for longer than 3 months. It is characterized as a complex sensory and emotional experience that varies according to the context, as well as the meaning of pain, and the psychological state of the individual [13]. Chronic pain has a significant impact on the individual and society [14]. Furthermore, it is considered a standalone condition, rather than a concomitant symptom of other ailments [15]; it causes sleep disruption, depression, and fatigue, as well as limitations in everyday activities and professional work [16]. Furthermore, it is associated with negative emotions and psychological distress [16]. Patients with chronic pain may experience, in certain situations, excessive emotional, cognitive, and behavioral responses [17]. However, the most important clinical symptom of chronic pain is the pain itself [18]. There is a positive correlation between the severity of chronic pain and the intensity of pain and the related phenomenon of outbreaks [18]. Chronic pain has a major impact on the quality of life of those who suffer from it [17,19,20][17][19][20]. Chronic pain is more common in women, elderly people, and the relatively deprived (e.g., those with lower socioeconomic status, disadvantaged geographical and cultural backgrounds, certain employment statuses and occupational factors, or a history of abuse or interpersonal violence) [21]. Several studies of chronic pain reported an inverse relationship between the occurrence of pain and the patient’s socioeconomic status [22,23][22][23]. More disadvantaged economic circumstances increase the likelihood of experiencing chronic pain [24]. About 1710 million people have this disease worldwide, including around 20% of the European population [16,21][16][21]. The best-known chronic pain diseases are fibromyalgia syndrome (FMS) [2[2][25][26],25,26], migraine [7], temporomandibular disorders (TMDs) [27], chronic musculoskeletal pain (CLBP) [1[1][28],28], and chronic neuropathic pain (CNP) [28]. FMS is a chronic widespread pain disorder characterized by generalized musculo-skeletal pain and numerous other symptoms, such as morning stiffness, fatigue, sleep disturbance (insomnia), anxiety, depression, mental decline, cognitive deficits, and reduced health-related quality of life [19,20,29,30,31][19][20][29][30][31]. FMS affects about 2–4% of the general population [32[32][33],33], with women being more predisposed to it than men [34]. However, the diagnosis of FMS seems to be gender biased, i.e., there is a tendency to overdiagnose FMS in women, even without applying the official criteria [34]. It is thought that overdiagnosis may be mainly due to a lack of knowledge, and a negotiated decision between the patient and doctor to satisfy certain psychosocial needs [34,35][34][35]. Although the etiology of FMS is unknown, central sensitization of pain (reflected in hyperalgesia and diffuse allodynia) seems to be the most plausible explanation [36,37][36][37]. This is probably due to the fact that FMS involves abnormal processing of pain in the central nervous system and inhibition of antinociceptive inhibitory mechanisms [36,37][36][37]. Migraine is an intense pulsing or throbbing pain in one area of the head lasting between 4 and 72 h, and associated with symptoms such as nausea, vomiting, sensitivity to light and sound, preceding neurological symptoms, etc. [38,39][38][39]. If migraine persists for more than 15 days a month, for at least 3 consecutive months, it is considered as chronic migraine. Migraine affects 10% of the population, and is more prevalent in women [39,40][39][40]. According to Ibrahimi et al. [41], in some women, migraine may be related to changes in hormone levels during the menstrual cycle. Chronic migraine is associated with several comorbidities such as obesity, obstructive sleep apnea, depression, and anxiety, and is also related to excessive use of caffeine and medications (e.g., opioids, barbiturates, and anti-inflammatory drugs) [38]. Pathological neurological and psychological aspects (e.g., a tendency toward perfectionism, rigid and obsessive personality, anxiety, and stress) seem to play a crucial role in the etiology of migraine [39]. TMDs are a group of diseases (temporomandibular joint disorders, masticatory muscle disorders, and disorders affecting associated structures) that affect the oral and maxillofacial region, involve the masticatory muscles and the temporomandibular joint, and can cause chronic pain [42]. The most common symptoms are generalized pain, psychological discomfort, orofacial pain, joint sounds, physical disability, and limitation of mandibular movements [42,43][42][43]. The prevalence of this disorder in the general population is between 30–50% [44], and it is more common in women [45]. TMDs have several comorbidities (sleep apnea, migraine, bruxism, neck pain, and biopsychosocial distress) that contribute to the development or persistence of symptoms [46,47][46][47]. However, it is not clear whether these comorbidities increase the risk of TMDs or simply coexist with them [48]. Currently, the frequency of somatic symptoms is considered to be the strongest predictor of TMD incidence [48]. Among the different types of chronic pain, CLBP lasts for at least 12 weeks [49], and affects the regions below the costal margin and above the inferior gluteal folds, with or without leg pain [50]. Patients with this disease mainly experience pain in the lower back [50]. Additionally, they exhibit impaired movement and coordination [51]. These disturbances affect the control of voluntary movements [51]. CLBP is the leading cause of disability and the most common of all non-communicable diseases [51,52][51][52]. This type of chronic pain has a worldwide prevalence of around 5–10% [16,53][16][53]; the prevalence is higher in females, people with less schooling, and smokers [54]. The overall prevalence has doubled over time due to changes in the workplace industry and lifestyles (it is associated with a higher prevalence of obesity, for example) [55]. CLBP is associated with functional cortical, neurochemical, and structural changes in several brain regions, including the somatosensory cortex [56]. CNP can be conceptualized as a pain caused by a lesion or disease of the somatosensory system [57,58][57][58]. The painful sensations that accompany CNP (e.g., burning, shooting, tingling, etc.) can be debilitating [59] and long-lasting, even with optimal medical treatment [60,61][60][61]. The most common conditions associated with this kind of pain are amputation, leprosy, painful radiculopathy, and trigeminal and postherpetic neuralgia [57]. The most frequent causes of CNP are lumbar and cervical painful radiculopathies [57]. About 6.9–10% of the general population suffers from CNP [21,59,62][21][59][62] and it is more frequent in women [59]. Chronic pain involves physical, psychological, and social factors [15]. The development of chronic pain is associated with risk factors, which are classified as “modifiable” and “non-modifiable” [15]. These include biological, sociodemographic, clinical, and psychological factors [15]. Cognitive and emotional factors strongly influence the connectivity of brain regions that modulate pain perception, emotional states, attention, and expectations [63]. According to imaging studies, the activity of afferent and descendent pain pathways is altered by the attentional state, and by positive and negative emotions [13]. The brain areas most involved in chronic pain are the somatosensory cortex, anterior cingulate gyrus, insula, and the prefrontal and inferior parietal cortices [64]. In addition to these areas, the regions most related to emotions (e.g., the insula, amygdala, and periaqueductal grey) are also involved in this disease [65].

2. Chronic Pain and Emotional Stroop

Regarding performance on the emotional Stroop task, greater processing of negative and/or positive words was observed in patients with FMS, suggesting the existence of an underlying interference process, triggered by events capable of immediately capturing attention (i.e., those conveying affective meaning) [78,81][66][67]. Studies such as that of Algom et al. [83][68] indicate that this interference effect in the emotional Stroop task is mediated by pre-attentive inhibition, associated with the threat of negative emotional stimuli presented during the task. However, this inhibition mechanism is considered to be independent from that of selective attention [83][68]. In FMS patients, delayed responses to pain words were associated with pain-specific anxiety and cognitive interference, as well as low sensitivity to anxiety [75][69]. Some studies indicated that the slowness in color naming during the emotional Stroop task seen in FMS patients is associated with the presence of a generalized hypervigilance response [12,26][12][26]. This response is associated with a tendency for FMS subjects to be slower with respect to the color naming of symptomatic (pain-related words) and arousing negative words, depending on the degree of perceived unpleasantness [9,26][9][26]. In patients with CLBP and FMS, attentional bias to sensory pain words was associated with the emotional load of the words presented in the emotional Stroop task [1,2,9,74][1][2][9][70]. This provides clear evidence of the presence of emotion-driven selective attention in FMS and CLBP [1,2,30,84][1][2][30][71]. In fact, the existence of attentional bias towards negative information seems to play an important mediating role in the relationship between a negative affective state and heightened pain [2,30,84][2][30][71]. In the study by Duschek et al. [2], such attentional bias was also observed in patients with FMS; they showed a specific bias towards negative information, which led to an increase in pain intensity. In CLBP, attentional bias was even greater in the context of words related to back pathology, and in association with increased pain intensity [1,76][1][72]. However, the causal nature of the relationship between attentional bias and pain could not be established, as most of the included studies used a cross-sectional design. On the other hand, there are data showing that individuals with greater attentional bias towards negative affective stimuli (i.e., words associated with pain) may be more prone to chronic pain symptoms [85][73]. In fact, attentional bias in these individuals may be a risk factor for the development of chronic pain and could also serve as a prognostic factor [71][74]. Attentional bias has been consistently linked to individuals’ anticipation and/or experience of pain across different chronic pain conditions [70,85][73][75].

In terms of neuronal activation, in patients with chronic pain in general, greater activation was observed when performing the emotional Stroop task [69][76]. Compared to the healthy group, greater activation in the anterior cingulate cortex, insula, and the primary and secondary somatosensory cortex was seen [69][76]. More specifically, pain-related words in the Stroop task were associated with significant differences between chronic pain patients and healthy controls, in terms of activation of the pain-processing centers of the brain (i.e., the anterior cingulate cortex, insula, parietal operculum, and the primary and secondary somatosensory cortices) [11,69][11][76]. Greater activation of brain areas related to attention, cognition, and motor planning in patients with TMDs compared to controls was also found [27]. TMD subjects showed increased task-evoked responses in prefrontal, lateral, and inferior parietal areas, as well as in the amygdala, pregenual anterior cingulate, primary motor areas, and the medial prefrontal and posterior cingulate areas [27,86][27][77]. In addition, patients also showed dissociations with respect to the activity of the prefrontal cortex and cingulate, and of the amygdala and cingulate, which are normally correlated [27,86,87,88][27][77][78][79]. Hence, the prominence of chronic pain (which requires attention) and slow behavioral responses may be explained by attenuated, or slow and/or desynchronized, recruitment of attentional processing areas [27,86,87,88][27][77][78][79].

Mindfulness-based psychological therapies seem to be a viable complementary treatment for people suffering from CNP [73,89][80][81]. Indeed, the reduction in cerebral activity observed after mindfulness treatment suggested that the emotionally charged words presented during the task had a diminished capacity to capture attention after the therapy compared to before the therapy [90,91][82][83].

In conclusion, after performing the emotional Stroop task, specific brain areas (e.g., the prefrontal cortex, somatosensory cortex, cingulum, and amygdala) related to emotional and pain processing are activated in patients with chronic pain (FMS, migraine, CNP, TMDS, and CLBP). During the task, chronic pain patients showed longer reaction times and delayed responses to words with negative emotional content. They also showed attentional biases towards pain sensory words. Therefore, the use of psychological therapies (e.g., mindfulness, cognitive, and cognitive behavioral therapies) will help reduce the brain activation and attentional bias produced by the emotional Stroop task in these patients.

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