Mindfulness-based Contemplative Training Reduces Avoidance and Facilitates Disengagement from Threat in Women Diagnosed with Fibromyalgia

Eight-week courses in mindfulness-based contemplative training focusing on specific meditation and yoga practices have been shown to have explicit benefits for many clinical disorders, especially with relation to treating stress, targeting emotion dysregulation, and attentional processes, yet little research has explored the effects of these practices in the context of bias. Attentional bias is a tendency to focus on one aspect of the environment over others. A bias may arise through varied mechanisms, but is driven by evolutionarily shaped mechanisms. Attentional bias will influence how one perceives and processes information in the present moment, from the past, and how one anticipates the future. Humans typically have their attention automatically captured by fear-relevant stimuli, and for good reason, to avoid danger and threat of harm.

Persistent attentional bias to threat cues in the environment will typically result in increased perception of danger, hypervigilance, and often frequent or intense experiences of anxiety. 

Although it may appear that an enhanced sensitivity to detecting threat is advantageous, hypervigilance is not necessarily adaptive, as it consists of persistent intensified monitoring and attentional fixedness at the expense of ongoing cognitive demands and a continually active sympathetic nervous system. Hypervigilance may also generalize to innocuous stimuli, wherein non-threatening stimuli are determined to be threatening. Thus, bias becomes a distorted interpretation of one’s experience, with consequences that could lead to chronic anxiety and stress-mediated pathology. Interestingly, there is now evidence that hypervigilant processing could be occurring without conscious awareness, such that very early stages of sensory processing (e.g., < 300 ms from stimulus exposure) are detecting possible threat-related cues. Once a threatening cue is detected, automatic and strategic forms of emotion regulation processing typically follow. Automatic forms of processing have the potential to operate below conscious awareness as well, and are typically over-trained, habitual responses to threat. Strategic forms of processing are more volitional, and cognitive in quality. Avoidance is one emotion regulation strategy that occurs at both automatic and strategic time-courses for the purpose of reducing elaborative or evaluative processing and deflating the threat value of the stimulus. When avoidance becomes habitual, it also can be maladaptive.

Both hypervigilance and avoidance have been found to contribute to the exacerbation of chronic pain and disability, and a vulnerability to pathological emotional states in chronic pain disorders like fibromyalgia (FM). FM is a disorder characterized by diffuse tenderness and widespread chronic pain, and is often accompanied by impaired cognitive, emotional, and physical functioning.

Although various external stimuli such as infection, trauma and stress may contribute to development of FM, recent studies have emphasized the role of hypervigilance and avoidance of pain-related information. Pain-related information are cues in the environment or recalled from one’s memory and can be anything from images, sounds, certain trigger words (e.g., sharp, pounding, throbbing), or even people that remind one of a past experience of pain. Because these cues have previously been associated with pain, a heightened sensitivity towards such pain-related information develops and leads to a generalized pattern of hypervigilance.My colleagues from the Utah Center for Exploring Mind-Body Interactions and I recently published a preliminary study in Cognitive Therapy and Research that investigated attentional bias of pain-related threat between women diagnosed with FM who went through an 8-week course of mindfulness-based contemplative training and an age-matched comparison control group of female FM individuals. The mindfulness-based training program was designed to accommodate the physical limitations of the FM population, but modeled after curriculum for Mindfulness-based Stress Reduction (MBSR) (see paper for exact modifications). A well validated dot-probe task (see paper for methodology of task) was used to explore early versus later stages of attentional bias processing of pain-related threat words. The rapid exposure of cues at short durations (100 ms) intended to capture automatic stages of processing by limiting attention to early sensory-perceptual stages, while longer cue durations (500 ms) intended to capture initial strategic forms of cognitive processing.

The data indicated that individuals from the control group appeared to be hypervigilant-avoidant in their processing of pain-related threat, such that pain-related words were rapidly detected and avoided without much time for conscious elaboration.

This form of avoidance is presumed to be a highly conditioned, automatized form of processing. Individuals from the control group also appeared to have difficulty disengaging from pain-related threat once strategic, elaborative processing was possible. This lingering engagement with negative stimuli slowed their response time on the dot-probe task, such that processing of threatening stimuli was assumed to interfere with the necessary processing for the task at hand (i.e., keyboard press indicating position of dot-probe). One may speculate that the mental stickiness that is typically described as a target for Buddhist meditation practices could also be explained by disengagement difficulty. Extended elaborative processing has also been implicated in ruminative cognition, a maladaptive, repetitive evaluation of one’s experience in a negative context.

The individuals exposed to mindfulness training demonstrated significantly less avoidance of threat than individuals from the control group and also disengaged more rapidly at later stages of processing.

These results suggest that mindfulness training reduces avoidance of pain-related threat at early levels of attention processing, and facilitates disengagement from threat at later stages of processing. Furthermore, it appears that effects of mindfulness training on early attentional threat processing do not remain stable after long-term follow-up. The enduring effects of mindfulness training on attentional bias were assessed 6-months after completion of the mindfulness-based program. With little to no continued meditation practice, the apparent effects on attentional bias were reduced. What did remain was a lack of attentional bias towards pain-related threat in comparison to neutral words.

The take-home message for this preliminary study is that mindfulness training for individuals diagnosed with FM appears to increase engagement with and decrease avoidance of pain-related information that normally leads to anxiety and emotion dysregulation. Furthermore, mindfulness training appears to decrease time of lingering or “mental stickiness” with pain-related information.

Further studies will have to investigate whether the decreases in bias after 6 months with little to no continued practice were indicative of a linear trend towards maladaptive avoidant emotion regulation strategies, or a stabilization of attention over time, in which no bias remains between threat and neutral stimuli. This study is the first preliminary evidence for the effect of mindfulness training on attentional bias. Future studies are also needed to clarify changes from pre- to post-meditation training using a mixed level of analysis, so that within and between group comparisons can be properly made.

Reference:

Vago, D.R. & Nakamura, Y. (2011). Selective attentional bias towards pain-related threat in fibromyalgia: Preliminary evidence for effects of mindfulness meditation training. Cognitive Therapy and Research, 6(35), 581-594. doi: 10.1007/s10608-011-9391-x