The role of experiential avoidance in acute pain tolerance: A laboratory test

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Abstract

The present investigation examined the role of experiential avoidance in terms of acute pain tolerance and subsequent recovery. Seventy nonclinical participants completed the Acceptance and Action Questionnaire [Hayes et al., The psychological record, 54 553–578] and underwent a well-established cold pressor task. Results indicated that individuals reporting higher levels of experiential avoidance had lower pain endurance and tolerance and recovered more slowly from this particular type of aversive event. Consistent with theoretical prediction, these findings suggest that experiential avoidance may play a role in tolerance of acute pain.

Introduction

Experiential avoidance (EA) denotes an affect-related regulatory process whereby persons are unwilling to remain in contact with certain private experiences (e.g., thoughts, emotions) and attempt to regulate the form, frequency, or contexts that occasion these experiences (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). Experiential avoidance is theorized to be a broad-based affective diathesis that is implicated in a variety of psychiatric problems (Blackledge & Hayes, 2001; Hayes et al., 1996). Available evidence suggests that while EA is believed to be a general diathesis, it is distinct from other vulnerability factors implicated in pain-related responding. Theoretically, EA is a process that subsumes other specific processes implicated in the pathogenesis of pain-related responding. Empirical evidence also has differentiated EA from cognitive processes implicated in prototypical types of emotion dysregulation. For instance, the global index of the anxiety sensitivity construct, as measured by the 16-item Anxiety Sensitivity Index (Reiss, Peterson, Gursky, & McNally, 1986) total score, shared only 9% of variance with EA, as indexed using the Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004), in an inpatient residential substance abuse population (Forsyth, Parker, & Finlay, 2003). Together, there is reason to believe the AAQ measures a psychological construct that is related to, but distinct from, other emotion vulnerability constructs and therefore may add unique explanatory power to models of pain-related responding.

Emerging empirical evidence supports EA as a broad-based vulnerability for emotional distress. First, deliberate attempts to suppress unwanted thoughts and negative emotions lead to greater amounts of such thoughts rather than less (Gold & Wegner, 1995; Gross & Levenson, 1997; Wegner, Schneider, Knutson, & McMahon, 1991; see Purdon, 1999, for a review). Second, EA, as indexed by the AAQ (Hayes et al., 2004), is elevated among women with, versus without, a history of childhood sexual abuse (Batten, Follette, & Aban, 2001) and mediates the relation between history of childhood sexual abuse and subsequent distress (Marx & Sloan, 2002). Third, higher AAQ scores are associated with problem drinking (Stewart, Zvolensky, & Eifert, 2002). Fourth, EA is significantly associated with various types of fear and anxiety (Feldner, Zvolensky, Eifert, & Spira, 2003; Forsyth, Parker, & Finlay, 2003; Karekla, Forsyth, & Kelly, 2004; Roemer, Salters, Raffa, & Orsillo, in press; Sloan, 2004; Zvolensky & Forsyth, 2002) and decreases with remission of such fears (Zettle, 2003). Collectively, the extant literature suggests that EA does, in fact, increase the probability of various types of emotional distress.

Despite the potential importance of EA, there unfortunately has been little attention applied to this construct in terms of better understanding pain-related experiences and problems. Consistent with the general prediction derived from EA theory, deliberate suppression of acute pain increases pain in future circumstances (Cioffi & Holloway, 1993). Additionally, acceptance of pain (i.e., openness to positive and negative aspects of human experience without deliberate defense), which is the antithesis of EA (Orsillo, Roemer, & Barlow, 2003), is associated with less pain-related disability and chronic pain (McCracken, 1998; McCracken, Spertus, Janeck, Sinclair, & Wetzel, 1999; McCracken, Vowles, & Eccleston, 2004). Additionally, a laboratory test of EA theory found that subjects randomly assigned to an acceptance condition during a cold pressor task tolerated greater levels of pain during a cold pressor task compared to control-based and placebo conditions (Hayes et al., 1999). Collectively, these pain-relevant studies suggest emotional avoidance processes may increase the intensity of pain experiences and acceptance strategies lead to better pain-related emotional adjustment.

Although the initial pain-related work on EA is promising, it is limited in a number of important respects. First, there have been few controlled laboratory tests of EA theory, necessitating the need for independent replication and extension. Second, no studies have examined the predictive validity of EA in terms of distress tolerance. Such neglect is unfortunate as recent research suggests the possibility that one's ability to tolerate both physical and psychological distress (i.e., distress tolerance) is a key determinant of emotional adaptation to aversive events (Brown, Lejuez, Kahler, & Strong, 2002; Zvolensky, Feldner, Eifert, & Brown, 2001). Finally, no studies have examined whether the observed EA findings are simply due to greater levels of emotional distress rather than EA processes per se. This limitation, specifically, detracts from the confidence one can have in the observed findings derived from extant studies on the topic.

Taken together, the overarching purpose of the present investigation was to provide a critical laboratory test of the predictive validity of EA in terms of a variety of theoretically relevant outcome variables in a well-established acute pain paradigm. Based on EA theory (Hayes et al., 1996) and past empirical work (Karekla et al., 2004), we hypothesized that individual differences in EA would predict (a) greater reactivity to physical stress, (b) delayed recovery from physical stress, and (c) decreased distress tolerance above and beyond demographic variables and pre-experimental anticipatory anxiety levels. Such a test offers a conservative examination of the predictive validity of EA in terms of physical distress tolerance beyond variables known to influence cold pressor responding.

Section snippets

Participants

Participants were 70 (45 females) undergraduate students at the University of Wisconsin-Stevens Point. The average age of participants was 20.18 (SD=3.67), and the ethnic composition was 94% (n=66) Caucasian, 1% (n=1) African American, and 4% (n=3) Asian American. Students participated in return for credit toward fulfilling a research requirement for an introductory psychology class. Selection criteria for inclusion in the study were an absence of pain-related problems (e.g., low back pain,

General data analytic strategy

Primary dependent measures included (1) self-reported pain intensity and pain recovery, (2) pain threshold, tolerance, and endurance times, and (3) heart rate. Hierarchical multiple regression analyses were performed with each of the primary dependent measures to test the incremental (or relative) predictive validity (Sechrest, 1963) of the AAQ in relation to acute pain above and beyond demographic variables and pre-experimental anxiety. Predictor variables were divided into three levels in the

Discussion

The present investigation examined a central tenet of contemporary conceptualizations of EA, namely, whether the construct demonstrates incremental explanatory power in terms of theoretically relevant indices of acute pain. As predicted, the current results indicate that EA is predictive of two primary dimensions of distress tolerance: AAQ scores demonstrated incremental predictive validity above and beyond demographic variables and anticipatory anxiety in relation to indices of (1) pain

Acknowledgements

This project was supported by a National Research Service Award predoctoral fellowship (F31 MH66430-01) awarded to the first author, National Institute on Drug Abuse research grants (R03 DA16307-01 and 1 R21 DA016227-01) and a Faculty Research Grant from the Anxiety Disorder Association of America awarded to the third author.

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