1. Cognition and Psychosocial Pain Treatment: Neuropsychological
Predictors of Outcomes in ACT for Chronic Pain
J.B. Robinson1, Matthew S. Herbert1, Niloofar Afari2, Julie L. Wetherell1
Introduction
• Pain and cognition are inversely related with greater pain predicting poorer
cognitive performance as well as history of cognitive problems predicting higher
self-reported experience of pain (Grossi et al., 2008; Ling et al., 2007).
• In addition, various cognitive domains appear to predict outcomes in patients
undergoing cognitive-behavioral type treatments for depression, anxiety disorders,
and schizophrenia (Caudle et al., 2007; Mohlman, 2005).
• No published works investigating the effects of cognition on psychosocial treatment
outcomes for pain were identified in our review of the literature.
• The current analysis is part of a non-inferiority study examining the effects of in-
person vs. telehealth Acceptance and Committment Therapy for chronic pain.
Aims:
• Determine if neuropsychological performance (NP) predicts treatment response
during 8-week ACT for chronic pain
• Determine if the relationship between group (telehealth vs. in-person) and
treatment response vary as a function of NP
• Determine if the relationship between time and treatment response vary as a
function of NP
1. VA San Diego Healthcare System and Department of Psychiatry, University of California, San Diego, San Diego, CA.
2. VA Center of Excellence for Stress and Mental Health and Department of Psychiatry, University of California, San Diego, San Diego, CA
Methods
Procedure:
A total of 121 Veterans with chronic pain (>6 months) were randomized to receive 8
weeks of either in-person or telehealth ACT for chronic pain. All participants
completed baseline neuropsychological testing.
Measures:
Pain Severity and Interference (assessed at all timepoints):
The Brief Pain Inventory - Short Form (BPI; Cleeland & Ryan, 1994)
Cognitive Function (assessed at baseline/termination):
Attention/Working Memory
WAIS-IV Letter-Number Sequencing subtest (Wechsler, 2008)
Processing Speed
WAIS-IV Symbol Search subtest (Wechsler, 2008)
Executive Function
Delis-Kaplan Executive Function System Color-Word Interference Test (Delis et
al., 2001)
Overall Premorbid Function
Vocabulary Task of the Wide Range Achievement Test, 4th Edition (WRAT-IV,
Wilkenson & Robertson, 2006)
Data Analysis:
Linear Mixed Modeling using SPSS (v.17)
Neuropsychological measures were centered and entered as covariates in order to
estimate the functional relation between NP and outcome (West, 2009).
Neuropsychological measures were entered into the model as fixed effects and
interaction terms were created with group and time.
Participant ID and the intercept were entered as random effects.
Recommendations
• Cognitive performance, at least for patients without a diagnosis of dementia or related deficits,
should not be considered in assigning patients to telehealth interventions for pain.
• Since previous investigators have found evidence for working memory predicting outcomes in
cognitive behavioral therapy for anxiety, it is possible that either the provision of ACT or
psychosocial treatment for pain are less susceptible to working memory deficits.
• Future research should seek to evaluate clinical and operational utility in using measures of
NP in assigning patients to treatments
Total
(N = 121)
Age: M (range) 51.93 (25-89)
Race
Caucasian: n (%) 67 (55.4)
African American: n (%) 37 (30.6)
Other: n (%) 17 (14.0)
Education
High school: n (%) 19 (15.8)
Some college: n (%) 41 (33.9)
Associate’s degree: n (%) 20 (16.5)
Bachelor’s or higher: n (%) 40 (33.0)
Marital Status
In Person: n (%) 62 (51.2)
Telehealth: n (%) 59 (48.8)
Discussion
• Neuropsychological measures of processing speed, executive function, and overall
premorbid function significantly predicted both pain severity and interference.
• NP in non-verbal working memory significantly predicted pain severity but not
interference.
• Baseline cognitive function appears to impact self-reported pain severity more so
than pain interference.
• NP variability for the current sample was restricted as all participants were generally of
average intellectual functioning. As a result, predictive ability was likely negatively
impacted by ceiling effects.
• Treatment modality (in-person vs telehealth) did not moderate the relation between
NP and outcome.
• Although baseline NP predicted overall treatment outcome, all measures of NP were
found to be insignificant when assessing the relation between time and treatment.
Pain Severity and Interference at Treatment Completion Predicted by Cognitive Performance at Baseline
Pain LNS SS Inhibition Inh-Switching WRAT
Severity
F -2.05 -3.76 -2.49 -1.52 -2.71
p .043 .000 .014 .132 .008
Interference
F -1.32 -3.41 -2.44 -0.86 -2.77
p .189 .001 .016 .395 .007
Note. LNS = Letter-Number Sequencing. SS = Symbol Search. WRAT = Vocabulary Task of the Wide
Range Achievement Test.