Recently, social support cues have been suggested to be "unique" safety signals possessing fear inhibitory properties. Yet, previous research only included autonomic fear measures (i.e., skin conductance) in passive fear conditioning procedures, therefore the impact of social support cues on operant pain-related avoidance learning and self-reported fear and pain-expectancy is unknown. In contrast, previous research showed that social threat cues facilitate pain-related fear learning, but their impact on operant pain-avoidance learning has never been investigated. Pain-free participants (N = 81) learned to avoid pain by performing increasingly effortful (in terms of deviation and force) arm-movements using a robotic arm. Participants were randomly assigned to one of three groups: Social Support (n= 27), Social Safety (n= 28), or Social Threat (n= 26). Social cues were manipulated by showing a picture of their supportive figure, a sex-matched smiling or angry stranger, respectively. We measured self-reported pain-expectancy and pain-related fear for the different arm-movements, contextual fear (fear-potentiated startle during the social cues), and avoidance behavior. Results showed successful acquisition of pain-related avoidance behavior and differential acquisition of self-reported fear and pain-expectancy. In contrast with our hypotheses, groups did not differ on any of the outcomes. Our findings suggest that in contrast to arousal-related fear measures, social support cues do not modulate avoidance behavior, nor self-reported pain-related fear and pain-expectancy in an operant pain-related avoidance paradigm. Potential explanations for this dissociation will be discussed. PERSPECTIVE: Social support cues did not attenuate acquiring pain-related fear and avoidance, nor did social threat cues facilitate such learning in an operant pain-avoidance learning task. Our results can inform future studies about the boundary conditions of social support and threat cues effects on fear and avoidance learning.

Using neuroimaging to understand the mechanisms of pain is an important task. But we must understand that the gold standard of measuring pain will always be the self-report.

Ample evidence shows that in-person social support can alleviate both acute and chronic pain complaints. However, less is known about the effectiveness of online social support. Disparities in availability of and access to in-person social support could make online social support a promising and cost-effective alternative. To this end we aimed to compare the effects of online versus in-person social support on pain induced with a cold-pressor task (CPT). Specifically, 62 pain-free female participants immersed their feet in cold water (1) alone, (2) in the physical presence of a supportive other, (3) while chatting with the supportive other online, and (4) while chatting online with a stranger, in a randomized order. We assessed self-reported pain intensity, pain unpleasantness, and threat value of pain, as well as pain tolerance (i.e. immersion time) and heart rate. Overall, pain intensity and unpleasantness ratings were higher in the alone condition compared to the other conditions. A similar pattern was found in pain tolerance, but the differences were not statistically significant. Heart rate increased during the CPT but was highest in the in-person support condition. Moreover, recovery after cold water immersion was slower in the alone condition compared to the other conditions. In sum, interaction with a supportive other or a stranger, be it online or in-person, led to a reduction in acute pain compared to being alone. This study presents initial evidence that online interaction with others might be an effective alternative to in-person social support in order to reduce acute pain in women. PERSPECTIVE: Online and in-person social support were equally effective in reducing acute experimental cold-pressor pain compared to being alone. There was no difference between social support from strangers or a supportive other.

The COVID-19 pandemic has profoundly impacted people with chronic pain, affecting their access to pain management services and the social fabric of society. Here we review evidence indicating that during and since the pandemic (1) the overall prevalence and burden of chronic pain has increased, (2) social threats such as social isolation, abuse and neglect, and disparities in access to pain management, have increased, and these changes are associated with worsening pain and pain-related health outcomes, and (3) there has been a surge in research into telehealth interventions for chronic pain, with promising results. We conclude with a discussion of lessons that may guide future research and care for people with chronic pain in a post-COVID world.

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. Perspective Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

ABSTRACT:Social support has been shown to reduce pain ratings and physiological responses to acute pain stimuli. Furthermore, this relationship is moderated by adult attachment styles. However, these effects have not been characterized in experimentally induced symptoms of chronic pain, such as secondary hyperalgesia (SH) which is characterized by an increased sensitivity of the skin surrounding an injury. We aimed to examine whether social support by handholding from a romantic partner can attenuate the development of experimentally induced SH. Thirty-seven women, along with their partners, participated in 2 experimental sessions 1 week apart. In both sessions, SH was induced using an electrical stimulation protocol. In the support condition, the partner was seated across from the participant holding the participant's hand during the electrical stimulation, whereas in the alone condition, the participant went through the stimulation alone. Heart rate variability was measured for both the participant as well as the partner before, during, and after the stimulation. We found that the width of the area of hyperalgesia was significantly smaller in the support condition. Attachment styles did not moderate this effect of social support on the area width. Increasing attachment avoidance was associated with both a smaller width of hyperalgesia and a smaller increase in the sensitivity on the stimulated arm. For the first time, we show that social support can attenuate the development of secondary hyperalgesia and that attachment avoidance may be associated with an attenuated development of secondary hyperalgesia.

Centre for the Psychology of Learning and Experimental Psychopathology, Faculty of Psychology and Educational Sciences, KU Leuven, Leuven, Belgium Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Virtual Reality (VR) may be a potential non-invasive and cost-effective alternative solution for the management of chronic pain. Previous studies have shown VR as a tool for reducing pain. The study’s aim was to investigate the benefits of VR, both fundamentally and holistically, for pain and body-image. For this study, an experimental protocol was designed using the Advanced Thermal Stimulator (TSA) to induce and resemble chronic pain. The study took place at Maastricht University and included a total of 47 healthy participants ranging in age from 18 to 35 years old. VR equipment and hardware were designed and provided by CUREosity. This study was conducted using a mixed 2 x 2 designs with VR condition (Active vs. Passive) and Time (First and Third Measurement) as the factors. The active condition was an interactive cold-water environment and the passive condition is a non-interactive forest ecosystem. Both of these conditions undergo the same procedure and were measured using the Pain Numeric Scale (PNS) scale. We hypothesized that pain perception will decrease in both conditions; with a significantly greater effect in the active compared to the passive condition. Additionally, we observe the variable body image without any directional assumption. The hypothesis was tested using a two-way repeated measures ANOVA. This was conducted for each dependent variable (pain perception and body image) with Pain Catastrophizing Scores (PCS) as a covariate. Results indicated that there was a significant interaction between PNS scores and condition; while no observed significant interaction was present for body image. These results suggest that VR may be beneficial as a clinical tool for reducing pain. In conclusion, future research may focus on improving current limitations; while observing the long-term benefits and applications of VR on chronic pain.

OBJECTIVE:Weight stigma is prevalent across multiple life domains, and negatively affects both psychological and physical health. Yet, research into weight stigma reduction techniques is limited, and rarely results in reduced antipathy toward higher-weight individuals. The current pre-registered study investigated a novel weight stigma reduction intervention. We tested whether a writing exercise focusing on body functionality (i.e., everything the body can do, rather than how it looks) of another person leads to reductions in weight stigma.METHOD:Participants were 98 women (Mage = 23.17, Range = 16-63) who viewed a photograph of a higher-weight woman, "Anne," and were randomised to complete a writing exercise either describing what "Anne's" body could do (experimental group) or describing her home (active control group). Facets of weight stigma were assessed at pretest and posttest.RESULTS:At posttest, the experimental group evidenced higher fat acceptance and social closeness to "Anne" compared with the active control group. However, no group differences were found in attribution complexity, responsibility, and likeability of "Anne".CONCLUSIONS:A brief body functionality intervention effectively reduced some, but not all, facets of weight stigma in women. This study provides evidence that functionality-focused interventions may hold promise as a means to reduce weight stigma.

K. Karos is a postdoctoral researcher supported by the Research Foundation, Flanders, Belgium (grant 1244820N). F. P. Kapos is a PhD candidate who is supported by the Patrick-Beresford Fellowship in Social Epidemiology and the P.E.O. International Peace Scholarship. H. Devan is a Postdoctoral Fellow supported by the Centre for Health, Activity and Rehabilitation Research (CHARR) Postdoctoral Fellowship at the School of Physiotherapy, University of Otago, New Zealand. This review was an initiative of the Social Aspects in Pain Special Interest Group (SocSIG) of the International Association of Pain (IASP).

Background Maladaptive defensive responses such as excessive avoidance behavior have received increasing attention as a main mechanism for the development and maintenance of chronic pain complaints. However, another defensive response which is commonly studied in animals as a proxy for fear is freezing behavior. No research to date has investigated human freezing behavior in the context of pain. In addition, there is an increasing realization that social context can affect pain-relevant processes such as pain experience and pain behavior but less is known about the effects of social context on defensive responses to pain. Hence, this study investigated freezing behavior and facial pain expression in the context of pain, and their modulation by social context. Methods Healthy, pain-free participants (N = 39) stood on a stabilometric force platform in a threatening or safe social context, which was manipulated using angry or happy facial stimuli. In some trials, an auditory cue (conditioned stimulus; CS) predicted the occurrence of painful electrocutaneous stimulus (unconditioned stimulus; pain-US). We assessed body sway (an index of freezing), heart rate, facial pain expression, self-reported pain intensity, unpleasantness, and pain-US expectancy during the CS and the context alone (no CS). Results The results were mixed. Neither the anticipation of pain, nor social context affected body sway. Heart rate and painful facial expression were reduced in the threatening social context at high anxiety levels. A threatening social context also elicited higher pain-US expectancy ratings. In sum, a threatening social context increases the expectation of pain, but reduces the facial expression of pain and lowers heart rate in highly anxious individuals.

Background and objectives: Amongst social contextual influences on pain, the manner in which pain and painful procedures are communicated to patients is considered an important contributor to the subjective experience of pain. Threatening information, e.g., by the use of technical language, is suggested to increase pain reports. Validation, or communicating understanding towards another person reporting personal experiences, is suggested to reduce pain. The current study examines effects of both information language (technical vs. plain language) and validation (validation vs. invalidation) on the subjective experience of experimentally induced pain. Methods: Pain-free participants (N = 132) were randomly assigned to one of four groups as formed by manipulations of validation and information language. After reading a description concerning the upcoming thermal stimulus formulated in technical or plain language, participants engaged in a computer controlled simulation (CCS; based on virtual reality technology). Participants received three thermal stimuli while interacting with an avatar who either validated or invalidated their experience during the CCS. Pain intensity and pain unpleasantness were assessed after each stimulus. Results: The validation manipulation showed to be effective, but the information language manipulation did not induce differential threat expectancies. Results show no effect of validation or information language on subjective pain reports. Limitations: Suboptimality of the information language manipulation and shortcomings of the CCS procedure might account for current findings. Conclusions: The study offers an interesting model for the further experimental study of isolated and combined effects of (social) contextual factors on pain. Diverse future research avenues are discussed.

See Related Article on p.623Chronic pain has become a health epidemic, with one in five U.S. adults suffering from chronic pain and an estimated annual cost of $560 billion in medical care, lost productivity, or disability services [[1]Kuehn B.M. News from the centers for disease control and prevention.J Am Med Assoc. 2018; 319: 2471Google Scholar]. Understanding pain has never been more crucial. Our current biopsychosocial understanding of pain explicitly recognizes the important role of the social dimension in explaining pain [[2]Gatchel R.J. Peng Y.B. Peters M.L. et al.The biopsychosocial approach to chronic pain: Scientific advances and future directions.Psychol Bull. 2007; 133: 581-624Crossref PubMed Scopus (1822) Google Scholar], and recently, it was proposed to update the official definition of pain to explicitly mention that pain encompasses not only sensory, emotional, and cognitive components but also social ones [[3]de C Williams A.C. Craig K.D. Williams A.C.D.C. Craig K.D. Updating the definition of pain.Pain. 2016; 157: 2420-2423Crossref PubMed Scopus (375) Google Scholar]. Yet, the conceptualization of pain as a social experience is still elusive. What does it mean to say that pain is also social? Systematic research in this area is still sparse, but it is now beyond doubt that social factors can powerfully modulate the experience of pain and, in turn, that pain impacts on a whole range of social factors. Pain challenges our social identity by making us dependent on others, by challenging our sense of justice and fairness, and ultimately, by challenging our feeling of belongingness [[4]Karos K. Williams A.C. de C. Meulders A. Vlaeyen J.W.S. Pain as a threat to the social self.Pain. 2018; 159: 1690-1695PubMed Google Scholar,[5]Krahé C. Springer A. Weinman J. a. Fotopoulou A. The social modulation of pain: Others as predictive signals of salience - a systematic review.Front Hum Neurosci. 2013; 7: 386Crossref PubMed Scopus (145) Google Scholar]. It is precisely in this last area of belongingness that most research has tried to understand the dynamic interplay between social factors and pain. See Related Article on p.623 The relationship between social exclusion and pain is well established. Chronic experiences of exclusion, such as bullying or loneliness, have been associated with an increased risk for ill health, including chronic pain [[6]Fekkes M. Pijpers F.I.M. Fredriks A.M. et al.Do bullied children get ill, or do ill children get bullied? A prospective cohort study on the relationship between bullying and health-related symptoms.Pediatrics. 2006; 117: 1568-1574Crossref PubMed Scopus (408) Google Scholar,[7]Voerman J.S. Vogel I. De Waart F. et al.Bullying, abuse and family conflict as risk factors for chronic pain among Dutch adolescents.Eur J Pain. 2015; 19: 1544-1551Crossref PubMed Scopus (35) Google Scholar]. Conversely, experiences of social exclusion and isolation are very common in people with chronic pain [[8]Piotrowski C. Chronic pain patients and loneliness: A systematic review of the literature. Loneliness in life: Education, business, society. McGraw Hill, NY2014Google Scholar,[9]De Ruddere L. Craig K.D. Understanding stigma and chronic pain.Pain. 2016; 157: 1Crossref PubMed Scopus (141) Google Scholar]. However, the underlying mechanisms of this interaction remain mysterious. A landmark study by Eisenberger et al. [[10]Eisenberger N.I. Lieberman M.D. Williams K.D. Does rejection hurt? An FMRI study of social exclusion.Science. 2003; 302: 290-292Crossref PubMed Scopus (2482) Google Scholar] led to a novel theory, proposing that physical and social pain share common neural pathways, which might explain the pervasive effect that these processes have on one another. As controversial as this idea has turned out to be [[11]Eisenberger N.I. Social pain and the brain: Controversies, questions, and where to go from here.Annu Rev Psychol. 2015; 66: 601-629Crossref PubMed Scopus (189) Google Scholar], it led to a wealth of systematic studies, which have illuminated the relationship between social exclusion and pain. For example, both experiences lead to activation in similar regions of the human brain. Moreover, increased sensitivity toward physical pain is associated with increased sensitivity to social exclusion, and vice versa. Finally, mechanisms to reduce one experience, such as painkillers, also reduced the intensity of social exclusion. However, this line of research has also resulted in a whole range of contradictory findings. Experimental manipulations of social exclusion have sometimes led to increased pain sensitivity, yet other studies demonstrated the analgesic effects of social exclusion [[12]Bernstein M.J. Claypool H.M. Social exclusion and pain sensitivity: Why exclusion sometimes hurts and sometimes numbs.Pers Soc Psychol Bull. 2012; 38: 185-196Crossref PubMed Scopus (136) Google Scholar]. It is in this context that the present study by Fales and Noel [[13]Fales J. Noel M. The effects of brief social exclusion on pain perception and pain memory in adolescents.J Adolesc Heal. 2020; 66: 623-625Abstract Full Text Full Text PDF Scopus (2) Google Scholar] can be situated. The authors investigate the effects of social exclusion on pain for the very first time in a sample of healthy adolescents rather than adults. This is an important first step because it is arguably in childhood and adolescence that experiences of social exclusion (e.g., bullying) are the most impactful and can pose a serious risk factor for the development of psychosocial and psychosomatic problems in adulthood [[6]Fekkes M. Pijpers F.I.M. Fredriks A.M. et al.Do bullied children get ill, or do ill children get bullied? A prospective cohort study on the relationship between bullying and health-related symptoms.Pediatrics. 2006; 117: 1568-1574Crossref PubMed Scopus (408) Google Scholar]. Understanding the underlying mechanisms in the transition from acute to chronic pain and the role of social experiences in this process could allow for preventative measures. Consequently, it is applaudable that researchers start to investigate these processes in adolescence. In addition, the authors are also interested in the role of pain memory after social exclusion, which can powerfully shape future pain and health behaviors [[14]Noel M. Pavlova M. McCallum L. Vinall J. Remembering the hurt of childhood: A psychological review and call for future research.Can Psychol. 2017; 58: 58-68Crossref Scopus (20) Google Scholar]. The authors can be commended for investigating another promising mechanism, which might shed light on the dynamic interplay between physical pain and social exclusion, namely memory. Surprisingly, the authors do not find any effect of social exclusion on pain reports, but they do show that social exclusion reduces the intensity with which pain is remembered compared with social inclusion. To explain their somewhat surprising findings, the authors refer to conditioned pain modulation, which might explain why social pain numbs the reaction to physical pain. Although this explanation is interesting, it indeed fails to explain why pain memory was affected but not immediate pain reports. Although this study is a first step in the right direction, it also highlights the challenges of the field and raises new questions. First and foremost, there is a clear lack of a comprehensive theoretical framework, which outlines the effects of different social factors on the perception of pain, which makes it difficult to generate specific and testable hypotheses. There is a whole range of interpersonal processes, which have been implicated in the exacerbation of pain, such as social isolation, exclusion, invalidation, injustice, and stigmatization [[4]Karos K. Williams A.C. de C. Meulders A. Vlaeyen J.W.S. Pain as a threat to the social self.Pain. 2018; 159: 1690-1695PubMed Google Scholar,[9]De Ruddere L. Craig K.D. Understanding stigma and chronic pain.Pain. 2016; 157: 1Crossref PubMed Scopus (141) Google Scholar]. Nonetheless, it is still unclear (1) how these different forms of social threat can be conceptualized, how they interact, and what their similarities and differences are; (2) under which circumstances they affect pain; and crucially (3) via which underlying mechanisms and pathways they can modulate the perception of pain and in which direction. An interesting proposal came from the study by Krahé et al. [[5]Krahé C. Springer A. Weinman J. a. Fotopoulou A. The social modulation of pain: Others as predictive signals of salience - a systematic review.Front Hum Neurosci. 2013; 7: 386Crossref PubMed Scopus (145) Google Scholar], which conceptualized social information as a predictive signal used by the brain to evaluate contextual threat or safety, which, in turn, influences the perceived salience of painful stimuli. Similarly, the very influential social communications model of pain outlines several different stages of a painful experience, which can be modulated by social factors but fails to make specific predictions based on individual social experiences [[15]Craig K.D. The social communication model of pain.Can Psychol. 2009; 50: 22-32Crossref Scopus (278) Google Scholar]. Finally, (4) it is crucial from a clinical perspective to understand how adaptive responses to social stress and pain can become maladaptive and cause chronic physical and psychosocial consequences. A developmental perspective, as taken in the present study by Fales and Noel [[13]Fales J. Noel M. The effects of brief social exclusion on pain perception and pain memory in adolescents.J Adolesc Heal. 2020; 66: 623-625Abstract Full Text Full Text PDF Scopus (2) Google Scholar], will clearly help to illuminate this transition. The modulation of pain by social context is complex, and we are just starting to get a glimpse of the myriad ways in which the social world can modulate experiences such as pain. The study by Fales and Noel [[13]Fales J. Noel M. The effects of brief social exclusion on pain perception and pain memory in adolescents.J Adolesc Heal. 2020; 66: 623-625Abstract Full Text Full Text PDF Scopus (2) Google Scholar] demonstrates that we still have a long way to go in understanding this modulation, but also that it is a worthwhile and paramount undertaking for the future. The Effects of Brief Social Exclusion on Pain Perception and Pain Memory in AdolescentsJournal of Adolescent HealthVol. 66Issue 5PreviewPeer relationship problems are associated with pain complaints; however, experimental data linking the two are lacking. The purpose of this study was to determine whether brief social exclusion influences pain processing in healthy adolescents. Full-Text PDF

Earlier research studying the effects of social threat on the experience and expression of pain led to mixed results. In this study, female participants (N = 32) came to the lab with 2 confederates. Both confederates administered a total of 10 painful electrocutaneous stimuli to the participant. The framing of the administration was manipulated in a within-subjects design: In the low social threat condition the participant was told that the confederate could choose between 10 and 20 pain stimuli, thus they believed that this confederate chose to administer the minimum allowed number of pain stimuli. In the high social threat condition the confederate had a choice between 1 and 10 stimuli, thus they believed that this confederate chose to administer the maximum allowed number of stimuli. Participants reported on the intensity, unpleasantness, and threat value of the painful stimuli, and their facial expression was recorded. Moreover, aggression and empathy toward the confederates were assessed. As hypothesized, participants reported increased pain intensity, unpleasantness, and threat in the high social threat condition compared to the low social threat condition, but showed less facial pain expression. Finally, participants exhibited increased aggression and reduced empathy toward the confederate in the high social threat condition. Perspective: Social threat reduces painful facial expression, but simultaneously increases pain reports, leading to a double burden of the person in pain. Additionally, social threat affected social relationships by increasing aggression and reducing empathy for the other. (C) 2020 U.S. Association for the Study of Pain. Published by Elsevier Inc. All rights reserved.