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.
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]. Studies such as that of Algom et al. [83] 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]. 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]. 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]. 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]. 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]. This provides clear evidence of the presence of emotion-driven selective attention in FMS and CLBP [1,2,30,84]. 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]. 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]. 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]. 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]. Attentional bias has been consistently linked to individuals’ anticipation and/or experience of pain across different chronic pain conditions [70,85].
In terms of neuronal activation, in patients with chronic pain in general, greater activation was observed when performing the emotional Stroop task [69]. Compared to the healthy group, greater activation in the anterior cingulate cortex, insula, and the primary and secondary somatosensory cortex was seen [69]. 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]. 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]. 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]. 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].
Mindfulness-based psychological therapies seem to be a viable complementary treatment for people suffering from CNP [73,89]. 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].
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.
This entry is adapted from the peer-reviewed paper 10.3390/jcm11123259