Pain: The Influence of Psychological Factors

The main study parameter is the mentalizing ability of the participants.

Mentalizing is the ability to understand the self and others in terms of

intentional mental states (e.g. feelings, wishes, desires, and values; Luyten &

Fonagy, 2014). Mentalization includes both emotional self-awareness as the

awareness for emotional signals in others. It has a cognitive component, the

Theory of Mind (ToM); being able to process, reflect on and express one's own

and others' intentions and emotional signals. Next, mentalization consists of

an emotional component; e.g. being able to experience empathy. The mentalizing

ability will be measured using the FHAT, the LEAS-SF and the RFQ.



The Frith-Happe-Animations task (FHAT; Abell, Happe, & Frith, 2000)

The FHAT is a performance-based task measuring theory of mind (ToM). It

comprises animated video-clips of 34 to 45 seconds. In these clips two

triangles exhibit movement patterns of living beings. Individuals with

well-functioning ToM will identify these objects as intentional. Therefore, the

FHAT shows a person's ability to recognize ToM in interpersonal situations,

while excluding most of the potentially confounding factors present in social

settings (Abell et al., 2000; Zunhammer et al., 2015). The FHAT has a

ToM-condition and a Goal-Directed(GD)-condition. The ToM-condition comprises of

four video-clips, in which two triangles display interaction suggesting

behavior described as ''Surprising'', ''Coaxing'', ''Mocking'', and

''Seducing''. These clips require ToM for correct interpretation. As a control,

the GD-condition is included, in which the triangles display behaviors which do

not require higher order mentalizing abilities to interpret correctly. These

behaviors are ''Fighting'', ''Following'', ''Chasing'', and ''Dancing''.

Participants are asked to describe what they have seen after each video-clip.

The responses will be scored on an Intentionality and an Appropriateness scale.

The 5-point Intentionality scale shows to what extent deliberate actions and

intentions are ascribed to the triangles. The 3-point Appropriateness scale

reflects how close the given response matches the content of the video, as

intended by the designers. A score of 3 is given for the correct interpretation

and a score of 0 is given for no answer or ''I don't know'' (Castelli, Happe,

Frith, & Frith, 2000).



The Levels of Emotional Awareness Scale - Short Form (LEAS-SF; Lane, Quinlan,

Schwartz, Walker, & Zeitlin, 1990)

The LEAS-SF is a performance-based task, proposed to measure the ability to

identify and describe emotions. It uses ten vignettes, each describing an

imaginary situation in which the participant interacts with a second person.

Participants are asked to give a verbal description of the emotions that the

situation may invoke in them and in the second person involved (Lane et al.,

1990; Zunhammer et al., 2015). The construct of emotional awareness is defined

as a type of cognitive processing which undergoes five levels of structural

transformation along a cognitive-developmental sequence of levels. These levels

are derived from an integration of developmental theories of Piaget and Werner.

The five levels of structural transformation are awareness of (1) bodily

sensations, (2) the body in action, (3) individual feelings, (4) blends of

feelings and (5) blends of blends of feelings. Answers of participants are

scored following these levels of emotional awareness (Lane, & Schwartz, 1987;

Subic-Wrana, Beutel, Garfield, & Lane, 2011; Zunhammer et al., 2015).



Reflective Functioning Questionnaire (RFQ; Fonagy et al., 2016)

The RFQ is a brief eight item questionnaire to assess mentalizing abilities.

Items are answered on a six-point Likert scale (1 = I do not agree at all to 6

= I very much agree). The RFQ has two subscales, Certainty (RFQ-C) and

Uncertainty (RFQ-U), each containing six items. Four items are used to

calculate scores on both subscales, while the other four items are unique to

each subscale. For a detailed description of scoring procedures see De

Meulemeester, Vansteelandt, Luyten, Lowyck, 2018 and Fonagy et al. 2016.

Research in French and Italian populations showed satisfactory reliability and

construct validity of the two subscales (Badoud et al., 2015; Morandotti et

al., 2018).

The secondary study parameters are childhood adversities, attachment style and

the quality of the patient-doctor relationship. Childhood adversities are

defined as maltreatment before the age of seventeen. This maltreatment can

consist of physical abuse, emotional abuse, sexual abuse, physical neglect, and

emotional neglect (Thombs, Bernstein, Lobbestael, & Arntz, 2009). The

occurrence and extent of childhood adversities are measured by the CTQ-SF.

Last, the experienced quality of the patient-doctor relationship is assessed by

the PDRQ-9 (Van der Feltz-Cornelis, Van Oppen, Van Marwijk, De Beurs, & Van

Dyck, 2004).



Childhood trauma questionnaire - Short Form (CTQ-SF; Bernstein et al., 2003)

The Childhood Trauma Questionnaire - Short Form (CTQ-SF) is a 28-item

retrospective self-report questionnaire designed to assess five dimensions of

childhood maltreatment: (1) Physical Abuse, (2) Emotional Abuse, (3) Sexual

Abuse, (4) Physical Neglect, and (5) Emotional Neglect. Items are scored on a

5-point Likert-scale and are structured to reflect the frequency of

maltreatment experiences (never true, rarely true, sometimes true, often true,

very often true). The psychometric properties of the Dutch CTQ-SF were found to

be satisfactory: internal consistencies were Cronbach's alpha .91 for Physical

Abuse, .89 for Emotional Abuse, .95 for Sexual Abuse, .63 for Physical Neglect,

and .91 for Emotional Neglect. In addition, scores on the five CTQ-SF scales

among Dutch respondents showed good convergent validity with responses on a

semi-structured interview for childhood trauma (Thombs et al., 2009).



The other secondary parameter is attachment style. Attachment styles can be

defined as internal working models with a specific set of mental

representations about the self in interaction with others that is developed in

the relationship with primary caregivers (Bowlby, 1969). Attachment styles are

relatively stable over time. In terms of their affective-motivational

characteristics, these global beliefs are referred to as anxiety about

rejection and abandonment and avoidance of intimacy and interdependence

(Crowell, Fraley, & Shaver, 1999). These two dimensions can be combined into

four attachment styles, one secure and three insecure subtypes: preoccupied,

dismissing and fearful (Bartholomew & Horowitz, 1991; Hinnen, Sanderman, &

Sprangers, 2009). Attachment style is measured by the ECR-M16.



The Experiences in Close Relationships Scale - Modified Short Form (ECR-M16;

(Lo et al., 2009)

The ECR-M16 is a 16-item self-report questionnaire designed to assess

attachment patterns in a variety of close relationships. Items are rated on a

likert-scale, ranging from 0 (strongly disagree) to 7 (strongly agree).

Participants receive the instruction ''The following statements concern how you

feel in close relationships with others. In the following statements the term

''other people'' refers to people to whom you feel close. Use the rating scale

to indicate how much you agree or disagree with each statement''. The

psychometric properties of the ECR-M16 were found to be satisfactory. The

internal consistencies of the scales were good, with Cronbach's alpha .83 for

attachment-related avoidance and Cronbach's alpha .84 for attachment-related

anxiety. The correlation between the two subscales was small, r = .27. Finally,

test-retest reliability was satisfactory, with a correlation of .73 for the

attachment avoidance subscale and .82 for the attachment anxiety subscale (Lo

et al., 2009).



Patient Doctor Relationship Questionnaire-9 (PRDQ-9; Van der Feltz-Cornelis et

al., 2004)

The PRDQ-9 is a brief measure of the doctor-patient relationship from the

patients perspective. The nine items are answered on a five-point Likert scale

(1 = not at all appropriate to 5 = totally appropriate). Two sample items are:

*my clinician understands me* and *my clinician and I agree on the nature of my

medical symptoms*. A mean score of all nine items is calculated. A higher score

means more satisfaction about the relationship. The psychometric quality of the

Dutch PDRQ-9 shows good internal consistency, adequate test-retest reliability

and the ability to discriminate between patient groups.