References of "van Ryckeghem, Dimitri 50022625"
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See detailEffects of cold stimulation on cardiac-vagal activation: Randomized controlled trial with healthy participants
Jungmann, Manuela; Vencatachellum, Shervin UL; van Ryckeghem, Dimitri UL et al

in Journal of Medical Internet Research (in press)

Background: The experience of psychological stress has not yet been adequately tackled with digital technology by catering to healthy individuals who wish to reduce their acute stress levels. For the ... [more ▼]

Background: The experience of psychological stress has not yet been adequately tackled with digital technology by catering to healthy individuals who wish to reduce their acute stress levels. For the design of digitally mediated solutions, physiological mechanisms need to be investigated that have the potential to induce relaxation with the help of technology. Research has shown that physiological mechanisms embodied in the face and neck regions are effective for diminishing stress related symptoms. The study described in this paper expands on these areas with the design for a wearable in mind. As this study charts new territory in research, it also represents a first evaluation of the viability for a wearables concept to reduce stress. We inquire into the effects of cold stimulation on heart rate (HR) and heart rate variability (HRV) in the neck region using a Thermode device. Objective: The objectives of this study were to assess whether (a) HRV is increased and (b) HR is decreased during a cold stimulation compared to a (non-stimulated) control condition. Effects were in particular expected in the neck and cheek regions and less in the forearm area (c). Methods: Participants were seated in a lab chair and tested with cold stimulation on the right side of the body. A Thermode was placed on the neck, cheek and forearm. Participants’ electrocardiogram was recorded and subsequently analyzed. The study was a fully randomized, within subject design. The cold stimulation was applied in 16 s intervals over 4 trials per testing location. The control condition proceeded exactly like the cold condition, except the thermal variable was manipulated to remain on the baseline temperature. HR was measured in msec IBI. rMSSD analyses were used to index HRV. Data were analyzed using a repeated measurements analysis of variance approach with two repeated measurements factors, i.e. Body Location (neck, cheek, forearm) and Condition (cold, control) Results: The data analysis of 61 participants (on exclusion of outliers) showed a main effect for body location for HR and HRV, a main effect for condition for HR and HRV and an interaction effect for condition and body location for HR and HRV. The results obtained demonstrate a pattern of cardiovascular reactivity to cold stimulation, suggesting an increase in cardiac-vagal activation. The effect was found to be significant for cold stimulation in the lateral neck area. Conclusion: The results confirmed our main hypothesis. This sets the stage for further investigations of the stress reduction potential in the neck region by developing a wearable prototype that can be used for cold application. Future studies should include a stress condition, test for a range of temperatures and durations, and collect self-report data on perceived stress levels to advance current findings. [less ▲]

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See detailAttentional bias to pain-related information: A meta-analysis of dot-probe studies
Todd, Jemma; van Ryckeghem, Dimitri UL; Sharpe, Louise et al

in Health Psychology Review (in press)

Studies investigating attentional biases towards pain information vary widely in both design and results. The aim of this meta-analysis was to determine the degree to which attentional biases towards pain ... [more ▼]

Studies investigating attentional biases towards pain information vary widely in both design and results. The aim of this meta-analysis was to determine the degree to which attentional biases towards pain occur when measured with the dot-probe task. A total of 2168 references were screened, resulting in a final sample of 4466 participants from 52 articles. Participants were grouped according to pain experience: chronic pain, acute pain, anticipating experimental/procedural pain, social concern for pain, or healthy people. In general, results revealed a significant, but small bias towards pain words (d= 0.136), and pain pictures (d= 0.110) in chronic pain patients, but not in those with acute pain, those anticipating pain, or healthy people. Follow-up analyses revealed an attentional bias towards sensory pain words in the chronic pain group (d= 0.198), and the acute pain group (d= 0.303), but not other groups. In contrast, attentional biases towards affective pain stimuli were not significant for any pain groups. This meta-analysis found support for attentional biases towards sensory pain stimuli in patients with chronic pain in comparison to healthy individuals across a range of common parameters. Future researchers need to consider task design when seeking to optimally measure pain-relevant attentional biases [less ▲]

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See detailParental emotion and pain control behaviour when faced with child’s pain: the emotion regulatory role of parental pain-related attention-set shifting and heart rate variability
Vervoort, Tine; Karos, Kai; Johnson, Dan et al

in Pain (in press)

, The present study investigated the moderating role of parental pain-related attention-set shifting and heart rate variability (HRV) for parental distress and pain control behaviour when faced with their ... [more ▼]

, The present study investigated the moderating role of parental pain-related attention-set shifting and heart rate variability (HRV) for parental distress and pain control behaviour when faced with their child’s pain. Participants were 54 school children and one of their parents. Parental HRV was assessed at study commencement followed by a cued switching task indexing parental ability to flexibly shift attention between pain-related and neutral attentional sets. In a subsequent phase, parents observed their child perform a CPT task, allowing assessment of parental pain control behavior (indexed by latency to stop their child’s CPT performance) and parental distress – assessed via self-report following observation of child CPT performance. Findings indicated that parental facilitated attentional shifting (i.e., engage) towards a pain-related attentional set contributed to higher levels of pain control behaviour when faced with increasing levels of chid facial display of pain. Pain control behaviour amongst parents who demonstrated impeded attentional shifting to a pain-related attentional set was equally pronounced regardless of low or high levels of child pain expression. Parental ability to shift attention away (i.e., disengage) from a pain related set to a neutral set did not impact findings. Results further indicated that whereas high levels of parental HRV buffers the impact of child facial pain display upon parental emotional distress and pain control behaviour, low levels of HRV constitute a risk factor for higher levels of parental distress and pain control behaviour when faced with increased child facial pain display. Theoretical/clinical implications and further research directions are discussed. [less ▲]

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See detailResilience factors in children with Juvenile Idiopathic Arthritis and their parents: the role of child and parent psychological flexibility.
Beeckman, Melanie; Hughes, Sean; van Ryckeghem, Dimitri UL et al

in Pain Medicine : The Official Journal of the American Academy of Pain Medicine (in press)

Objective: Chronic pain is central to Juvenile Idiopathic Arthritis (JIA) and is predictive of impaired functioning. Whereas most work has focused on identifying psychosocial risk factors for maladaptive ... [more ▼]

Objective: Chronic pain is central to Juvenile Idiopathic Arthritis (JIA) and is predictive of impaired functioning. Whereas most work has focused on identifying psychosocial risk factors for maladaptive outcomes, we explored the idea that child and parental psychological flexibility (PF) represent resilience factors for adaptive functioning of the child. We also explored differences between general versus pain-specific PF in contributing to child outcomes. Methods: Children with JIA (8-18 years) and (one of) their parents were recruited at the department of pediatric rheumatology at the Ghent University Hospital in Belgium. They completed questionnaires assessing child and parent general and pain-specific PF and child psychosocial and emotional functioning, and disability. Results: The final sample consisted of fifty-nine children and forty-eight parents. Multiple regression analyses revealed that child PF contributed to better psychosocial functioning and less negative affect. Child pain acceptance contributed to better psychosocial functioning, lower levels of disability and lower negative affect, and also buffered against the negative influence of pain intensity on disability. Bootstrap mediation analyses demonstrated that parental (general) PF indirectly contributed to child psychosocial functioning and affect via the child’s (general) PF. Parent pain-specific PF was indirectly linked to child psychosocial functioning, disability, and negative affect via child pain acceptance. Conclusion: Our findings indicate that child and parental PF are resilience factors and show that pain acceptance buffers against the negative impact of pain intensity. Implications for psychosocial interventions that target (pain-specific) PF in children as well as in parents are discussed. [less ▲]

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See detailDoes attention bias modification training impact on task performance in the context of pain: An experimental study in healthy participants
van Ryckeghem, Dimitri UL; Van Damme, Stefaan; Vervoort, Tine

in PLoS ONE (2018)

Attention has been theorized to play a key role in the experience of pain and associated task interference. Training attention away from pain via attention bias modification (ABM) training techniques has ... [more ▼]

Attention has been theorized to play a key role in the experience of pain and associated task interference. Training attention away from pain via attention bias modification (ABM) training techniques has been proposed to improve pain-related outcomes, but evidence is inconsistent. In an experimental study, we investigated the impact of a single session ABM training -using a visual probe paradigm with idiosyncratic pain words- on cold pressor test (CPT) pain experience and task interference by pain. Fifty-eight healthy volunteers were randomly assigned to an ABM training group (N = 28; attending away from pain) and a sham training group (N = 30; no training direction). At pre-training, participants performed a baseline Random-Interval-Repetition (RIR) task and the CPT. Participants reported on sensations they experienced during the baseline CPT. Relevant descriptors were integrated in the visual probe paradigm during the training phase. At post-training, participants completed the RIR task again while experiencing CPT pain. Participants also reported on the extent they attended to the pain and the intensity/unpleasantness of the pain. Results indicated that, in contrast with our hypotheses, ABM training did also not reduce task interference due to CPT pain. Furthermore, ABM training did not change self-reported attending to CPT pain. Finally, ABM training did not reduce CPT pain intensity or pain unpleasantness. Overall, the current study provides no support for the effectiveness of a single session ABM training in improving pain-related outcomes. Future research addressing the conditions under which ABM training improves or fails to improve pain-related outcomes is warranted. [less ▲]

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See detailTask interference and distraction efficacy in patients with fibromyalgia: an experimental investigation
van Ryckeghem, Dimitri UL; Rost, Silke; Kissi, Ama et al

in Pain (2018), 159(6), 1119-1126

Pain has the capacity to interfere with daily tasks. Although task interference by pain is largely unintentional, it can be controlled to a certain extent. Such top-down control over pain has been thought ... [more ▼]

Pain has the capacity to interfere with daily tasks. Although task interference by pain is largely unintentional, it can be controlled to a certain extent. Such top-down control over pain has been thought to be reduced in fibromyalgia patients. In this study, we investigated task interference and distraction efficacy in fibromyalgia patients (FM) and a matched healthy control group. Forty-nine fibromyalgia patients and 49 heathy volunteers performed as quickly as possible (a) a visual localization task in the presence of non-painful vibrating or painful electric somatic stimuli, and (b) a somatosensory localization task (using non-painful or painful stimuli). Participants reported on their experience of the somatic stimuli on some of the trials during both localisation tasks. Results indicated that pain interferes with performance of the visual task, in both FM patients and healthy individuals. Furthermore, participants experienced the pain stimulus as less intense when directing attention away from the pain than when focusing on the pain. Overall, task performance of FM patients was slower compared to the task performance in the healthy control group. In contrast to our hypotheses, FM patients and healthy volunteers did not differ in the magnitude of the interference effect and distraction-efficacy. In conclusion, current study provides support for contemporary theories claiming that attention modulates the experience of pain and vice versa. However, no evidence was however found for an altered attentional processing of pain in fibromyalgia patients. Furthermore, results indicate that task interference and distraction-efficacy are not just two sides of the same coin. [less ▲]

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See detailPain and Attention: Towards a Motivational Account
van Ryckeghem, Dimitri UL; Crombez, Geert

Book published by Oxford University Press (2018)

Attention plays a pivotal role in the experience of pain and its impact upon daily activities. Accordingly, research on the interplay between attention and pain has a long scientific history. Within this ... [more ▼]

Attention plays a pivotal role in the experience of pain and its impact upon daily activities. Accordingly, research on the interplay between attention and pain has a long scientific history. Within this chapter, we discuss the theoretical frameworks that aim to explain the relationship between attention and pain. We argue for a motivational perspective on pain that highlights the critical role of cognitive, affective and contextual factors in explaining the interplay between attention and pain. To substantiate this argument, we provide an overview of available research addressing the bottom-up capture of attention by pain and the top-down modulation (both inhibition and facilitation) of attention for pain. We conclude this chapter with guidelines and suggestions for future research and discuss clinical implications of adopting a motivational perspective on pain. [less ▲]

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See detailCognitive biases in pain: current challenges, future directions and treatment opportunities
van Ryckeghem, Dimitri UL

in Canadian journal of Pain (2018)

Cognitive biases are a core component of contemporary cognitive-affective models that try to explain pain experience, distress and disability in children and adults experiencing pain. The idea that ... [more ▼]

Cognitive biases are a core component of contemporary cognitive-affective models that try to explain pain experience, distress and disability in children and adults experiencing pain. The idea that children and adults with pain show cognitive biases for pain-related information, i.e. they selectively attend to pain-related information at the cost of other information (attentional bias), interpret ambiguous stimuli as pain-related (interpretation bias) or have biased memories for painful events (memory bias), has been particularly influential in this context. Notwithstanding the considerable progress made in the understanding of cognitive biases related to pain and threat, a number of questions remains unanswered and future challenges linger. A first challenge is to further delineate the characteristics of cognitive biases, including their content specificity and dynamics. A second challenge relates to the understanding of how cognitive biases interrelate with each other and possibly reinforce one another. A third challenge relates to the translation of findings on cognitive biases for pain into clear strategies and recommendations to optimize and evaluate pain treatment programs. Presenters in this symposium will address each of the above-mentioned lingering challenges by both critically reviewing the available evidence on cognitive biases in children and/ or adults experiencing pain and presenting novel research using innovative study set-ups and unique methods for assessing and modifying cognitive biases in children and adults experiencing pain. [less ▲]

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See detailAttention bias modification training for adolescents with chronic pain: A randomized placebo-controlled trial
Heathcote, Lauren C; Jacobs, Conrad; van Ryckeghem, Dimitri UL et al

in Pain (2018), 159(2), 239-251

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See detailThe efficacy of attentional distraction and sensory monitoring in chronic pain patients: A meta-analysis
van Ryckeghem, Dimitri UL; Van Damme, Stefaan; Eccleston, Chris et al

in Clinical Psychology Review (2018), 59

Attentional strategies, such as distraction and sensory monitoring, are often offered to reduce pain and pain-related distress. However, evidence for their efficacy in chronic pain patients is equivocal ... [more ▼]

Attentional strategies, such as distraction and sensory monitoring, are often offered to reduce pain and pain-related distress. However, evidence for their efficacy in chronic pain patients is equivocal. We report a meta-analysis on the efficacy of distraction and sensory monitoring in chronic pain patients, and explore possible methodological and theoretical moderators. The scientific literature was searched for relevant articles, which were coded for methodological quality and several theoretical and methodological moderator variables. Only 10 articles fulfilled the search criteria. Eight studies allowed us to compare distraction with a control condition, two studies to compare sensory monitoring with a control condition, and four studies to compare the effect of distraction with the effect of sensory monitoring. Overall, results indicate that distraction did not differ from control in altering pain experience (k=8; Hedges’ g=0.10, ns) and distress (k=2; Hedges’ g=0.549). Sensory monitoring did also not alter pain experience (k=2; Hedges’ g=-.21, ns) and distress (k=1; Hedges’ g=-0.191, ns). We found no evidence to support the superiority of distraction or sensory monitoring in altering pain compared to control conditions. We offer guidance for future theory-driven research to investigate distraction and sensory monitoring in this largely unexplored field, albeit one replete with methodological difficulties. [less ▲]

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See detailThe interference of pain with task performance: Increasing ecological validity in research
van Ryckeghem, Dimitri UL

in Scandinavian Journal of Pain (2017), 16

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See detailAttentional processing of itch
van Laarhoven, Antoinette; van Damme, Stefaan; Lavrijsen et al

in Psychological Research (2017)

Itch is a prevalent somatosensory symptom thatcan be highly disabling , because it is likely to drawattention and, as a resu lt, may interfere with the perfor-mance of daily activities. Yet, research ... [more ▼]

Itch is a prevalent somatosensory symptom thatcan be highly disabling , because it is likely to drawattention and, as a resu lt, may interfere with the perfor-mance of daily activities. Yet, research experimentallyinvestigating attention to itch is lacking. In this study weaimed to investigate attentional processing of itch usingmultiple behavioral attention tasks. Forty-one healthyparticipants performed (1) a modified Stroop task with itch-related words, (2) a dot-probe task with itch-related pic-tures, and (3) a rece ntly developed somatosensory attentiontask in which the effect of experimentally induced itch onthe localization of visual targets was examined. Addition-ally, a number of self-report questionnaires related tosomatosensory attentional processing were administered.Results indicated that participants’ attention was biasedtoward itch-related words and pictures assessed by meansof the dot- probe and modified Stroop task, respectively. Forthe somatosensory attention task, results showed that itchdid not significantly influence the allocation of attention.However, when taking into account the time course ofattention during the itch stimulus, data suggested thatparticipants tended to disengage attention away during theitch stimulus. This is the first study that indicates anattentional bias for itch, using methods that have previouslybeen validated for other sensations such as pain. In addi-tion, the newly developed somatosensory attention taskmay reflect the time course of attention toward a tonic itchstimulus. [less ▲]

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See detailGeneralized hypervigilance in fibromyalgia: normal interoceptive accuracy, but reduced self-regulatory capacity
Rost, Silke UL; van Ryckeghem, Dimitri UL; Schulz, André UL et al

in Journal of Psychosomatic Research (2017), 93(2), 48-54

Objective: The factors underlying the aetiology of fibromyalgia (FM) are largely unknown. According to the generalized hypervigilance hypothesis (GHH), FM patients show excessive attention towards pain ... [more ▼]

Objective: The factors underlying the aetiology of fibromyalgia (FM) are largely unknown. According to the generalized hypervigilance hypothesis (GHH), FM patients show excessive attention towards pain stimuli and other sensory events, thereby increasing pain perception and dysfunctional behaviour. We tested this notion by assessing interoceptive accuracy (IA) in FM patients and matched healthy controls. We also tested the hypothesis that FM is characterized by reduced self-regulatory capacity as indexed by heart rate variability (HRV). Methods: 47 FM patients (Mage = 45.5, 39 females) and 45 healthy controls (Mage = 44.9, 37 females) completed several self-report scales (Body Vigilance Scale, Depression Anxiety Stress Scales, Pain Catastrophizing Scale). To derive HRV, heart rate was monitored under resting conditions; for the assessment of IA participants performed a heartbeat tracking task in which they were asked to silently count their heartbeats. Results: FM patients reported higher body vigilance than healthy controls, but there were no group differences in IA. FM patients had lower HRV compared with healthy controls. HRV did not predictor IA. Conclusion: In conclusion, our findings do not support the hypothesis of generalized hypervigilance in FM patients. Patients reported a heightened focus on bodily sensations, which was not reflected in IA. It may be that hypervigilance is not a general and stable characteristic but is rather context dependent and modality-specific. [less ▲]

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See detailDo tonic itch and pain stimuli draw attention towards their location?
Van Laarhoven, Antoinette; Van Damme, Stefaan; Lavrijsen, A. P. et al

in BioMed Research International (2017)

Background: Although itch and pain are distinct experiences, both are unpleasant, and may demand attention and interfere with daily activities. Research investigating the role of attention in tonic itch ... [more ▼]

Background: Although itch and pain are distinct experiences, both are unpleasant, and may demand attention and interfere with daily activities. Research investigating the role of attention in tonic itch and pain stimuli, particularly whether attention is drawn to the stimulus location, is scarce. Methods: In the somatosensory attention task, fifty-three healthy participants were exposed to 35-seconds electrical itch or pain stimuli on either the left or right wrist. Participants responded as quickly as possible to visual targets appearing at the stimulated location (ipsilateral trials) or at the arm without stimulation (contralateral trials). During control blocks, participants performed the visual task without stimulation. Attention allocation at the itch and pain location is inferred when responses are faster ipsilaterally than contralaterally. Results: Results did not indicate that attention was directed towards or away from the itch and pain location. Notwithstanding, participants were slower during itch and pain than during control blocks. Conclusions: In contrast with our hypotheses, no indications were found for spatial attention allocation towards the somatosensory stimuli. This may relate to dynamic shifts in attention over the time course of the tonic sensations. Our secondary finding that itch and pain interfere with task performance is in line with attention theories of bodily perception. [less ▲]

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See detailATTENTIONAL BIASES IN PAIN: A META-ANALYSIS OF DOT PROBE RESEARCH
Todd, J.; Sharpe, L.; van Ryckeghem, Dimitri UL et al

in INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE (2016), 23(1), 119

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See detailThe Effect of Perceived Injustice on Appraisals of Physical Activity: An Examination of the Mediating Role of Attention Bias to Pain in a Chronic Low Back Pain Sample.
Trost, Zina; van Ryckeghem, Dimitri UL; Scott, Whitney et al

in The journal of pain (2016), 17(11), 1207-1216

The current study examined the relationship between perceived injustice and attentional bias (AB) toward pain among individuals with chronic low back pain asked to perform and appraise the pain and ... [more ▼]

The current study examined the relationship between perceived injustice and attentional bias (AB) toward pain among individuals with chronic low back pain asked to perform and appraise the pain and difficulty of a standardized set of common physical activities. A pictorial dot-probe task assessed AB toward pain stimuli (ie, pain faces cueing pain), after which participants performed the physical tasks. Participants also rated face stimuli in terms of pain, sadness, and anger expression. As hypothesized, perceived injustice was positively associated with AB toward pain stimuli; additionally, perceived injustice and AB were positively associated with appraisals of pain and difficulty. Counter to expectations, AB did not mediate the relationship between perceived injustice and task appraisals, suggesting that AB is insufficient to explain this relationship. Exploratory analyses indicated that participants with higher levels of perceived injustice rated stimulus faces as sadder and angrier; no such differences emerged for pain ratings. To our knowledge, this is the first study to examine the association between perceived injustice and AB toward pain, as well as perceived injustice and in vivo appraisals of common physical activity. Results extend existing literature and suggest that attentional and potential interpretive bias should be considered in future research. PERSPECTIVE: This article identifies significant associations between perceived injustice, biased attention to pain, and appraisals of common physical activities among individuals with chronic low back pain. These findings suggest targets for intervention as well as directions for future research regarding individuals with high perceptions of injustice related to pain. [less ▲]

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See detailTowards an integrative view of cognitive biases in pain.
van Ryckeghem, Dimitri UL; Vervoort, Tine

in European journal of pain (London, England) (2016), 20(8), 1201-2

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See detailA componential emotion approach for the assessment of emotional awareness in youth.
Veirman, Elke; Fontaine, Johnny R. J.; van Ryckeghem, Dimitri UL

in Psychological assessment (2016), 28(11), 1416-1426

The Levels of Emotional Awareness Scale for Children (LEAS-C) is a performance-based instrument that assesses emotional awareness in the structure of written responses to a set of real-life scenarios ... [more ▼]

The Levels of Emotional Awareness Scale for Children (LEAS-C) is a performance-based instrument that assesses emotional awareness in the structure of written responses to a set of real-life scenarios. While it is theoretically expected that emotional awareness develops with age, virtually no age differences have been established with the LEAS-C. The present study investigated whether an adaptation of the instructions and scoring procedure on the basis of the componential emotion approach could improve the validity of the LEAS-C and reveal the theoretically expected age differences. An adapted LEAS-C was administered to a sample of 574 children and adolescents and scored with the original and a new componential scoring procedure. An acceptable reliability for the original and a good reliability and a high interrater reliability for the componential scoring procedure were observed. Multigroup confirmatory factor analyses showed measurement invariance of factor loadings and intercepts across children (8 to 12 years) and adolescents (13 to 16 years) for all tested models, for both scoring procedures. A one-factor model fitted well for the total scores and self and other scores for both scoring procedures. The pattern of relationships with alexithymia, emotional intelligence, intelligence, personality, and social and emotional impairment as well as gender differences were comparable with prior research. Furthermore, the expected relationship with age was found, with stronger correlations for the componential than the original scoring procedure. In conclusion, analyses of the reliability, internal structure, and nomological network supported the adaptations of the LEAS-C on the basis of the componential emotion approach. (PsycINFO Database Record [less ▲]

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See detailPerceived injustice explains pain intensity over and above attentional bias.
Bell, T.; Trost, Z.; van Ryckeghem, Dimitri UL et al

in Journal of Pain (2016), 17(4, 1), 32

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See detailA Systematic Review and Meta-analysis of Interventions for Sexual Health Promotion Involving Serious Digital Games.
DeSmet, Ann; Shegog, Ross; van Ryckeghem, Dimitri UL et al

in Games for health journal (2015), 4(2), 78-90

OBJECTIVE: Serious games may be effective in promoting sexual health behavior. Their confidential nature may encourage users to discuss sensitive sexuality topics. Furthermore, they can tailor messages to ... [more ▼]

OBJECTIVE: Serious games may be effective in promoting sexual health behavior. Their confidential nature may encourage users to discuss sensitive sexuality topics. Furthermore, they can tailor messages to the individual's needs and may be intrinsically motivating. This meta-analysis investigates the effectiveness of interventions for sexual health promotion that use serious games. MATERIALS AND METHODS: A database search was conducted in PubMed, Web of Science, CINAHL, and PsycINFO for publications before the end of July 2013. Serious digital games studies measuring effects on behavior or its determinants, using a control condition, allowing the calculation of an effect size (Hedges' g, random-effects model) were included. RESULTS: Seven game studies for sexual health promotion were included. These showed positive effects on determinants (g=0.242; 95 percent confidence interval, 0.129, 0.356), albeit of small effect size. The effects on behavior, measured in only two studies, were not significant (g=0.456; 95 percent confidence interval, -0.649, 1.561). Most games did not use many game features that are considered to be immersive or enhancing flow. Instead, there was a strong reliance on pure gamification features, such as rewards and feedback. CONCLUSIONS: The effectiveness of the next generation of games may be enhanced by building on the behavioral change and educational gaming literatures (e.g., using role-play and simulation game formats, individual tailoring, offering adaptation in the difficulty of the challenge, and amount and timing of the feedback). There is a need for studies with rigorous evaluations of game effectiveness, longer-term follow-up, and using measures of behavior rather than merely their determinants. [less ▲]

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