Cognitive Pain Modulation in Young and Older Adults: Understanding the Role of Individual Differences in Frontal Functioning

Cognitive pain modulation is integral to our quality of life and deeply interwoven with the success of pain treatments but is also characterized by large interindividual variations. Emerging evidence suggests that one of the driving factors behind these variations are individual differences in frontal functioning. Further evidence indicates that pain-related cognitions, and possibly also emotional distress, may influence the efficacy of pain modulation.

Central aim of this project was to assess the role of individual differences in frontal functioning in cognitive pain modulation, with a specific focus on older adults. With respect to this, we also wanted to assess whether individual differences in frontal functions could explain conflicting previous results on age-related changes in the efficacy of cognitive pain modulation. In addition, we wanted to address the role of negative pain-related mindsets and emotional distress on the efficacy of cognitive pain modulation. We tested these research questions across four different studies using two prime paradigms of cognitive pain modulation, namely distraction from pain and placebo analgesia.

In Study I, we assessed the role of individual differences in executive functions, emotional distress, and pain-related cognitions in modulating heat pain thresholds in healthy young adults in virtual reality environments with different levels of cognitive load. We found that emotional distress and visuo-spatial short-term memory significantly predicted how participants responded to the low vs high load environment.

In Study II, we investigated the role of different forms of cognitive inhibition abilities and negative pain-related cognitions in modulating the efficacy of distraction from (heat) pain by cognitive demand in healthy young adults. We found a significant influence of better cognitive inhibition and selective attention abilities on the size of the distraction effect; however, this association was moderated by the participant’s level of pain catastrophizing, i.e., high pain catastrophizers showed an especially strong association.

In Study III, we tested potential age-related differences in distraction from pain in a group of young and older adults while simultaneously acquiring functional brain images. We found no age-related changes at the behavioural level, but a slightly reduced neural distraction effect in older adults. The neural distraction effect size in older adults was furthermore significantly positively related to better cognitive inhibition abilities.

In Study IV, we explored potential age-related differences in placebo analgesia in a group of young and older adults (who were partly re-recruited from Study III) while recording their brain activity with an electroencephalogram. Results revealed no age-related differences in the magnitude of the behavioural or electrophysiological placebo response, but older adults showed a neural signature of the placebo effect that was distinct from young participants. Regression analyses revealed that executive functions that showed an age-related decline (as established via group comparisons) were significant predictors of the behavioural placebo response. We furthermore found that better executive functions significantly moderated the association between age group and placebo response magnitude: older adults with better executive functions showed a larger placebo response than young adults whereas worse executive functions were associated with a smaller placebo response, possibly explaining why we found no significant difference at the group level.

In summary, all studies provide converging evidence that differences in cognitive functions can significantly affect the efficacy of cognitive pain modulation. Although older adults showed a significant decline in most cognitive functions that we assessed, we found no systematic reduction in the efficacy of cognitive pain modulation (except for a slight reduction in the neural distraction effect size). Closer inspection of the data revealed that older adults may have engaged compensatory mechanisms that enabled them to experience the same (or even higher) level of pain relief as younger adults. We furthermore found evidence for the notion that pain-related cognitions and emotional distress may affect how individuals respond to cognitive pain modulation although this association was less systematic than for cognitive functions.

Overall, the present thesis adds to the emerging body of evidence highlighting the importance of executive functions, as indicators of frontal functioning, in cognitive pain modulation.