Commentary: Attentional biases and their role in the management of pain

Attentional biases refer to the degree to which individuals prioritize the processing of information towards salient stimuli. Attentional biases are typically assessed through one or more experimental paradigms, such as the modified Emotional Stroop Task [5], the dot-probe paradigm [2] or a visual or spatial cueing paradigm [6]. Over the past decade, there has been increasing interest in the contribution of attentional biases to pain. The dotprobe has been the paradigm most frequently used to compare the attentional biases of pain patients and healthy controls. Essentially, the dot-probe paradigm presents pairs of pain-related and neutral stimuli to participants and asks them to respond to a probe that appears following the presentation of the stimulus pair. Attentional bias is inferred if the time to respond is quicker when the probe replaces the pain-related stimulus in comparison to when it replaces the neutral stimulus. Schoth et al. [7] recently conducted a meta-analysis of all dot-probe studies that compared patients with pain conditions with healthy controls. The results demonstrated clearly that chronic pain patients do indeed demonstrate attentional biases to painful stimuli (words and pictures) in comparison to healthy controls [7]. However, the degree to which these biases are simply a consequence of current pain is unknown. Therefore, studies that investigate the role of attentional biases in the development, maintenance or management of pain are urgently needed. The article in this issue of Pain by Van Ryckeghem et al. [11] advances this field of research by asking the question whether initial attentional biases towards painful stimuli can predict the efficacy of a strategy previously shown to reduce pain, at least in some settings: namely distraction away from pain. Using a spatial cueing task, Van Ryckeghem and colleagues assessed the attentional bias of a group of 53 healthy control subjects. They replicated their earlier finding that an attentional bias towards painful stimuli was evident. However, the real contribution of this study lies in its finding that the attentional bias at baseline predicted change in the level of pain reported in a second test where participants were instructed to use distraction. This finding is important because it suggests that attentional biases, where present, may be a barrier to participants being able to make use of a strategy (distraction) that is commonly used spontaneously by people to manage pain and that is often part of pain management programs. If attentional biases impede the utility of distraction, is it equally possible that there are interventions that might be more effective for people with attentional biases to painful stimuli? The most obvious treatment that might be expected to be more efficacious for people with pre-existing attentional biases is attention bias modification (ABM). Attentional bias modification (ABM) was designed specifically to manipulate attentional biases using a modified version of the dot-probe task where the probe never follows the pain-related stimuli. In this paradigm, there is implicit