Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2022 Feb 1.
Published in final edited form as: Rehabil Psychol. 2020 Mar 9;66(1):57–64. doi: 10.1037/rep0000316

Behavioral Activation and Behavioral Inhibition: An examination of function in chronic pain

Aaron P Turner 1,2, Mark P Jensen 2, Melissa A Day 3, Rhonda M Williams 1,2
PMCID: PMC7483151  NIHMSID: NIHMS1566676  PMID: 32150432

Abstract

Purpose/Objective:

To examine the BIS-BAS model of chronic pain. This model posits that 2 neurophysiological systems - the behavioral inhibition system (BIS) sensitized to and activated by punishment cues and the behavioral activation system (BAS) sensitized to and activated by reward cues - make independent and concurrent contributions to two domains of pain-related function: pain interference and positive function despite pain. The study additionally hypothesized that BIS and BAS sensitivity would have different associations with these two different aspects of pain-related function. BIS activation would be more strongly correlated with pain interference and BAS would be more strongly correlated with positive function despite pain.

Research Method/Design:

Cohort study consisting of the baseline assessments of 328 Veterans enrolled in a large clinical trial examining 3 psychosocial interventions for chronic pain.

Results:

In multivariable regression adjusting for demographic factors and pain intensity, BIS was associated with greater pain interference and less positive function despite pain. BAS was associated with greater positive function despite pain, but to a lesser degree than BIS.

Conclusions:

As hypothesized, BIS and BAS both contributed to pain-related function; however, BIS displayed stronger associations with both pain interference and positive function despite pain. Thus, the hypothesis that BIS-BAS relationships would differ based upon the nature of the functional outcome (BIS resulting in poorer function due to pain and BAS better function despite pain) was only partially supported. Findings of the current study suggest the role of BIS in chronic pain may be more pervasive across functional outcomes.

Keywords: Chronic Pain, Behavioral Activation, Behavioral Inhibition

Introduction

Chronic Pain is a significant public health problem affecting nearly 100 million adults in the US, and is estimated to incur costs of over $500 billion dollars annually in health care expenses and lost productivity (IOM, 2011). Chronic pain is of particular relevance to rehabilitation professionals both because individuals with disability often experience chronic pain (citation), but also because of its independent and pervasive impact on both physical and psychosocial function. Pain disrupts goal-directed attention and behavior (Eccleston & Crombez, 1999) and is associated with poorer physical function (IOM, 2011; Takeyachi et al., 2003), anxiety and depression (Asmundson & Katz, 2009; Bair, Robinson, Katon, & Kroenke, 2003), lower levels of social and community participation (Dawu et al., 2019; Wilkie et al., 2016) and ultimately poorer quality of life (IOM, 2011).

Over the past several decades, an increased understanding of the complex interchange of biological, psychological and social factors that contribute to chronic pain has emerged. Biopsychosocial models have provided a framework for understanding the mechanisms that contribute to the development and persistence of pain and have informed the expansion of intervention targets beyond the purely medical domain.

One important behavioral mechanism is engagement in valued activity despite pain. Several theoretical models with separate but related conceptual underpinnings have hypothesized the presence of 2 distinct processes that contribute to goal directed behavior: a first process reflecting approach behavior and a second process reflecting avoidance behavior (Gable, Reis, & Elliot, 2000; Jensen, Ehde, & Day, 2016; Watson, Wiese, Vaidya, & Tellegen, 1999). Approach behavior reflects behavioral initiation and persistence. It is hypothesized to be associated with emotions such as hope and excitement and cognitive content reflecting self-efficacy. Avoidance behavior, on the other hand, reflects behavioral withdrawal. It is hypothesized to be associated with emotions such as depression and anxiety and cognitive content such as perceived hopelessness (Jensen et al., 2016).

A particularly useful articulation of approach and avoidance processes is found in the Behavioral Inhibition/Behavioral Avoidance System (BIS-BAS) model, founded in large part on Gray’s reinforcement sensitivity theory. The BIS-BAS model hypothesizes 2 underlying neurophysiological systems activated by environmental cues and sustained by associative learning. The first is the behavioral inhibition system (BIS) that is sensitized to, and activated by, cues associated with punishment. The second is the behavioral approach (or activation) system (BAS) that is both sensitized to, and activated by, cues associated with reward. The two systems are thought to operate simultaneously and, although related and can influence each other, are thought to act independently (Gray, 1990; Gray & McNaughton, 2003).

Although the BIS-BAS model characterizes behavior in general, it can readily be applied to the specific situation of pain and the impact of pain on function. From the perspective of a BIS-BAS model of chronic pain, individuals with chronic pain and a tendency to have an activated BIS are hypothesized to be both sensitized to, and activated by, the experience of pain as a likely cue for punishment. This is hypothesized to result in initiating a ramp up of an interconnected network of avoidance-related thoughts (e.g., pain catastrophizing), emotions (e.g., anxiety), and behavior (e.g., activity avoidance) (Day, Matthews, Newman, Mattingley, & Jensen, 2019). On the other hand, individuals with chronic pain and a tendency to have an activated BAS are hypothesized to be more sensitized to, and activated by, other rewarding characteristics of the context in which pain occurs. This would result in the activation of alternate networks, including those that underlie approach-related thoughts (e.g., pain control beliefs), emotions (e.g., positive mood), and behavior (e.g., engagement) (Day et al., 2019). The BIS-BAS model provides a more nuanced systems approach to understanding both the initiation and maintenance of pain than that afforded by a general biopsychosocial disease framework. It also has the capacity to inform precision pain treatment approaches implemented in rehabilitation settings.

A growing but limited literature has begun to examine the BIS-BAS model with respect to pain and pain-related function. Day and colleagues (2019) examined cognitive, emotional, and behavioral constructs associated with a BIS-BAS model of pain within a chronic low back pain sample. As predicted, BIS and BAS displayed positive correlations among measures of the domains within each system (i.e., BIS was positively associated with measures of domains hypothesized to be BIS-related, and BAS was positively correlated with measures of domains hypothesized to be BAS-related), and negative correlations between the measures of the domains between the two systems. In addition, measures of the BIS- and BAS-related domains were associated with pain intensity. However, inconsistent with one of the hypotheses the BIS-BAS model, Day et al. (2019) found a stronger association between BAS-related measures and pain intensity then between BIS-related measures and pain intensity. In another study, Jensen and colleagues (2015) examined a BIS-BAS model of pain in headache. As hypothesized, individuals with higher BIS activity reported greater pain intensity and headache frequency. Higher BAS activity was associated with lower headache frequency. Looking beyond pain intensity, only one study has examined the BIS-BAS model with respect to pain-related behavioral function. Consistent with the BIS-BAS model, Serrano-Ibanez and colleagues (2019) found that BIS activity, but not BAS activity was associated with greater pain-related impairment.

A broader understanding of the applicability of the BIS-BAS model of pain within a heterogeneous chronic pain sample that is adequately powered to test the framework would differentiate the simultaneous and distinct contributions of both BIS and BAS activation to pain-related function. A tendency to have a more active BIS would be expected to foster inhibition and avoidance of valued behavior in the presence of pain (maladaptive pain-related function). At the same time, a tendency to have a more active BAS would be expected to support engagement in valued behavior despite pain (adaptive pain-related function). The present study sought to test these hypotheses by examining the associations between a measure of behavioral inhibition and behavioral activation system sensitivity and two separate pain-related functional outcome domains. We hypothesized that, after adjusting for key demographic characteristics and pain intensity, (1) trait behavioral inhibition sensitivity would be associated with greater pain interference (maladaptive function in response to pain), (2) trait behavioral activation sensitivity would be associated with greater positive function despite pain and finally (3) consistent with hypotheses 1 and 2, if both BIS and BAS were independently and simultaneously associated with pain-related functional outcomes, BIS would be more strongly associated with pain interference and BAS would be more strongly associated with adaptive pain function.

Method

Design

This study used data collected from the baseline assessment point for a large clinical trial comparing three group-based interventions for chronic pain (hypnosis, mindfulness meditation and psychoeducation). Additional details on the trial design are reported elsewhere (Williams et al., 2020).

Participants

Participants were Veterans recruited via self-referral (9% of enrolled participants), clinician referral (40% of enrolled), and focused medical record review (51% of enrolled). Inclusion criteria included: (a) Veteran status, (b) age 18 years or older, (c) English proficiency, (d) self-reported pain for at least 3 months with an average intensity of 3 or greater (0–10 scale) over the past week, (e) worst pain intensity of 5 or greater (0–10 scale) over the past week, and (f) pain experienced at least 75% of the time over the past 3 months. Exclusion criteria included: (a) cognitive impairment measured via 2 or more incorrect responses on a 6-item cognitive screener psychometrically derived from the Mini Mental State Exam,(Callahan, Unverzagt, Hui, Perkins, & Hendrie, 2002) (b) psychosis, thought disorder, or hospitalization for psychiatric conditions other than suicidality, homicidality, or planned PTSD treatment over the past 5 years, (c) severe or unstable mental health functioning within the past 6 months, (d) daily use of greater than 120mg morphine equivalent dosage medication, (e) group-interfering behavioral problems, (f) active suicidal or homicidal ideation or related behaviors, (g) difficulties with telephone communication, and (h) planned life events that may interfere with group participation.

Procedure

All data in the present manuscript were gathered at baseline, prior to randomization, via a combination of telephone calls and one in-person interview. Intervention classes were offered simultaneously at pre-established start times in cohorts. The Positive Function Despite Pain measure was not added to the study protocol until cohort 4 of the parent study. Thus, the current study sample reflects only those participants recruited from this timepoint until the completion of enrollment. This study was approved by the VA Puget Sound and University of Washington Institutional Review Boards.

Measures

Demographics (co-variates).

Demographic information including age, gender, and race were collected on all participants. As all demographics were categorized as covariates, study categorical variables were collapsed into dichotomous categories as follows: gender (male/female), race (white/other).

Pain intensity (co-variate).

Pain intensity over the past week was measured using the Numerical Rating Scale (NRS). Participants rated their average pain over the past 24 hours from 0 (No pain) to 10 (Pain as bad as you can imagine). The NRS was administered up to four times within one week to calculate the average pain intensity over the past week, with each assessment separated by at least 24 hours. The NRS as a composite measure of average pain intensity is more reliable than single rating measures (Dworkin et al., 2005; Jensen, Turner, & Romano, 1994), and demonstrates strong validity (Jensen, 2010). Higher scores indicate greater pain intensity.

Pain interference (co-primary outcome).

Pain interference over the past week was measured with the 6-item Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Short-Form self-report questionnaire. Participants rated how much chronic pain interfered with various functional domains (e.g., day to day activities, work around the home) over the past week from 1 (not at all) to 5 (very much). The final value is expressed as a T-score with higher scores indicating greater pain interference. The PROMIS pain interference questionnaire has well-established validity (Cella et al., 2010; Cook et al., 2016). Internal consistency in the current sample was excellent (α = .90).

Positive function despite pain (co-primary outcome).

Positive function despite pain was measured with the 8-item PROMIS Psychosocial Illness Impact Positive Short-Form self-report questionnaire with pain as the identified illness. Participants were asked to report on the achievement of positive pursuits (e.g., meaningful relationships, appreciating each day) “before your pain” and “since your pain” on a scale ranging from 1 (not at all) to 5 (very much). Per standard scoring instructions, the “since your pain” score was utilized to reflect current positive functioning despite pain. The final value is expressed as a T-score with higher scores reflecting greater positive functioning. The underlying item bank from which this static psychosocial impact positive short-form was derived has established validity (Lai, Garcia, Salsman, Rosenbloom, & Cella, 2012). Internal consistency in the current sample was good (α = .89).

Behavioral Inhibition and Behavioral Activation System sensitivity.

Behavioral inhibition and behavioral activation sensitivity were assessed using the 20-item BIS-BAS scale (Carver & White, 1994), consisting of 7 items examining BIS sensitivity (e.g., “I worry about making mistakes”) and 13 items examining three domains of BAS sensitivity Drive (e.g., “I go out of my way to get things I want”), Reward Responsiveness (e.g., “When I’m doing well at something I love to keep at it”), and Fun Seeking (e.g., “I crave excitement and new sensations”). Given existing data suggesting the 3 activation subscales reflect a supra-ordinate BAS factor (Campbell-Sills, Liverant, & Brown, 2004), these subscales are often combined to produce a BAS total score (Jensen et al., 2015). This approach, producing one BIS and one BAS sensitivity score, was utilized in the present study. Respondents rated each BIS-BAS item on a 4-point Likert scale ranging from 1 (Very true for me) to 4 (Very false for me) that were then reverse scored so that higher values reflected greater activation of the respective system. BIS-BAS scales have established general (Carver & White, 1994) and pain-specific validity (Jensen et al., 2015). Internal consistency in the current sample was acceptable for BIS (α = .77) and good for BAS (α = .84) scales.

Data Analysis Plan

Descriptive statistics were calculated for all study variables including means and standard deviations (continuous measures) and frequency counts (dichotomous measures). In addition, Pearson correlation coefficients were computed between pairs of the primary study variables for descriptive purposes. To test the study hypotheses, hierarchical multiple regression was used to examine the association between the measures of behavioral inhibition/behavioral activation sensitivity and two pain-related functional outcomes: pain interference (model 1) and positive function despite pain (model 2). For both models, demographic factors were entered as a block in step 1. Pain intensity was entered in step 2, and the BIS-BAS scale scores were entered simultaneously in step 3.

Results

The study sample consisted of 328 Veterans with chronic pain who completed baseline assessments and were subsequently randomized to one of three interventions. Demographic information, as well as mean scores for pain and BIS-BAS are reported in Table 1. Univariate correlations are reported in Table 2. Demographic variables were largely unrelated to BIS-BAS, with the exception that females endorsed higher levels of BIS (r = −.13). Individuals who identified as white endorsed lower levels of pain intensity and pain interference (rs ranging −.13 to −.19). BIS was associated with higher pain interference (r = .14) and lower positive function despite pain (r = −.39). BAS was associated with greater positive function despite pain (r = .17). Please see Table 2.

Table 1.

Sample Characteristics

M(SD) N(%)
1. Age 53.17 (13.10)
2. Gender (M) 241 (73.5)*
3. Race (White) 207 (63.1)*
4. Pain Intensity 5.78 (1.69)
5. Pain Interference 63.98 (5.27)
6. Positive Function Despite Pain 40.16 (9.29)
7. Behavioral Inhibition 19.02 (4.01)
8. Behavioral Activation 39.25 (6.15)
Open in a new tab

Note. N = 312–328. Positive Function Despite Pain N = 262. Gender = Male/Female. Race = White/All other. Education = College Graduate or Higher/All Other.

*

Absolute percentages not adjusted for limited (<1%) missing data.

Table 2.

Correlations of study variables

1 2 3 4 5 6 7 8
1. Age −.05 −.10 −.02 .01 .02
2. Gender (M) −.13* .01 −.03 −.03 .03
3. Race (White) .07 −.03 −.19** −.13** −.05
4. Behavioral Inhibition −.01 −.02 .14* −.39**
5. Behavioral Activation .02 −.02 .17**
6. Pain Intensity .44** −.18**
7. Pain Interference −.31**
8. Positive Function Despite Pain
Open in a new tab

Note. N = 312–328. Positive Function Despite Pain N = 262

*

p<.05

**

p<.01

***

p<.001

Pain Interference

The results of hierarchical regression examining pain interference (model 1) are presented in Table 3. As hypothesized, after adjusting for demographic variables (age, gender, race) and average pain intensity, the BIS scale score was associated with higher levels of pain interference (β = .13, p<.05, ΔR2 = .02, ΔF = 3.16, p<.05). Individuals who reported higher levels of behavioral inhibition sensitivity endorsed greater pain interference (maladaptive pain-related function). The BAS scale score, on the other hand, made a weak and non-significant unique contribution to the prediction of pain interference. Although the beta value for race on the first step was also significant, the associated proportion of variance accounted for at that step was not.

Table 3.

Results from Hierarchical Regression Examining Behavioral Inhibition, Behavioral Activation, and Pain-Related Outcomes

Model 1: Pain Interference B SE β ∆R2 ∆F
Step 1 .02 1.91
 Age 0.00 0.02 .01
 Gender −0.53 0.67 −.05
 Race −1.37 0.60 −.13*
Step 2 .17 64.14***
 Pain Intensity 1.28 0.16 .43***
Step 3 .02 3.16*
 BIS 0.16 0.07 .13*
 BAS 0.02 0.04 −.02
Model 2: Positive Function Despite Pain B SE β ∆R2 ∆F
Step 1 .01 0.96
 Age 0.03 0.05 .04
 Gender 1.07 1.35 .05
 Race −1.53 1.21 −.08
Step 2 .03
 Pain Intensity −0.91 0.35 −.17** 6.97**
Step 3 .17
 BIS −0.83 0.13 −.37*** 24.66***
 BAS 0.27 0.09 .18**
Open in a new tab

Note. ∆R2 = change in r-squared value for that step. ∆F = change in F-value corresponding to that step.

β = beta value for variable.

*

p<.05

**

p<.01

***

p<.001.

Positive Function Despite Pain

The results of hierarchical regression examining positive function despite pain (model 2) are also presented in Table 3. After adjusting for demographic variables (age, gender, race) and average pain intensity, the BAS scale score was significantly associated with higher levels of positive pain function despite pain or adaptive pain-related function (β = .18, p<.01). The BIS scale score was also associated with positive function despite pain (β = −.37, p<.001), with, higher BIS was associated with lower positive function. Interestingly, and inconsistent with the BIS-BAS model of pain as originally formulated, the BIS scale score was more strongly associated with positive function despite pain than the BAS scale score. Together the BIS and BAS scale scores accounted for significant variance at that step (ΔR2 = .03, ΔF = 24.66, p<.001).

Discussion

The BIS-BAS model proposes that behavioral inhibition and behavioral activation are distinct neurophysiological systems that operate as behavioral “brake pedals” and “gas pedals” in response to environmental cues in daily life. In the context of chronic pain, being sensitized to and activated by pain as a cue for punishment (BIS) or reward (BAS) is hypothesized to influence the perception, experience and in particular the functional impact of pain. The current analyses focused on the last of these three elements. We hypothesized that measures of BIS and BAS sensitivity would be associated with simultaneous but also unique impact on different aspects of pain-related function. Specifically, we expected individuals who endorsed higher levels of behavioral inhibition (BIS), and who were therefore sensitized to experience pain as a cue for punishment, to report a greater negative impact of chronic pain upon their daily function (pain interference). Individuals who endorsed higher levels of behavioral activation (BAS), and were therefore sensitized to reward cues associated with pain, were expected to report better positive daily function despite that pain. Study results provided partial support for these hypotheses, and have important theoretical and clinical implications for individuals seen in rehabilitation settings.

Theoretical Implications

As hypothesized, individuals with higher levels of BIS sensitivity endorsed a larger negative impact of chronic pain on function, even after adjusting for the average intensity of the pain they are experiencing. In addition, individuals with higher levels of BAS sensitivity endorsed a greater ability to sustain positive aspects of function despite pain. Consistent with the model, BAS sensitivity was more strongly associated with positive function despite pain than with pain interference, supporting a unique role for BAS sensitivity in this “positive” outcome. However, inconsistent with the BIS-BAS model of pain as originally presented, we found that the absolute value of the strength of association between BIS and positive function was larger than that between BAS and positive function. One possible explanation for this result is that BAS sensitivity may also predispose individuals to short term reinforcement related to pain (e.g., partner solicitousness encouraging inactivity) but that would not be considered longer term positive functioning despite pain. Thus, it would be important to know which responses, specifically, BAS sensitivity was actually activating, given that the relationship between this system and positive function may be complicated by the types of reinforcement available in a person’s environment.

The current findings extend and elaborate on the only other study to date examining the BIS-BAS model and pain-related functional outcomes. Serrano-Ibanez and colleagues (2019) found that a measure of BIS sensitivity but not BAS sensitivity was associated with greater pain-related physical impairment (similar to pain interference). Overall, the current findings highlight the importance of both systems, although they also suggest that BIS may have a more pervasive impact on all aspects of pain-related function (i.e., inhibition due to pain or persistence despite pain). If the current findings are replicated in other samples of individuals with chronic pain and in studies using other measures of BIS and BAS sensitivity, they would suggest that some modification of the BIS-BAS model of chronic pain is warranted. Specifically, the idea that BAS is more strongly associated with “BAS-related” outcomes (e.g., in this case, positive function despite pain) than BIS is would need to be modified. Instead, and in the context of chronic pain, it may be that across all outcomes, “positive” (including approach responses) and “negative,” BIS may play a larger role (or a more direct and less complicated role) than BAS. It is also possible that specific patterns of pain-related thoughts, behavior and emotions associated with these sensitivities might change over time. Future work could examine the role of BIS-BAS sensitivity on functioning with shorter and longer durations of chronic pain. As discussed below, the specific roles that BIS versus BAS sensitivity play in functional outcomes is important to understand, because they have important and distinct clinical implications.

Clinical Implications

The results of this study can be interpreted in the context of current theory examining the components of pain treatments and are helpful for understanding patient-specific factors that may contribute to the differential efficacy of treatments for particular individuals with chronic pain in rehabilitation settings. BIS and BAS sensitivity may be viewed as both trait-like predispositions that can be used to predict treatment response and future actions, as well as state-like patterns of behavior that can be modified. Given the evidence from the current study that both BIS and BAS sensitivity play independent roles as predictors of patient function (albeit, as already discussed, the BIS plays a larger role across more outcome domains; the BAS plays a smaller role, and its effects may be more limited to positive outcomes), these findings suggest that both BIS and BAS sensitivity may be important to target in individuals with chronic pain; doing so may increase the overall benefits that patients can get from pain treatment.

A recently developed model of pain treatment moderators – the Limit, Activate, Enhance (LA&E) model (Day, Ehde, & Jensen, 2015) – provides some guidance regarding a flexible approach to treating pain. In the LA&E model, different pain treatments or treatment components can be characterized as those that (1) limit unhelpful and over-utilized behavioral patterns and coping responses, (2) activate helpful but under-utilized behavior and coping, and/or (3) enhance or take advantage of existing positive behavior and coping. Conceptually, the BIS-BAS model can inform how one uses the LA&E model, i.e., understanding the degree to which BIS-BAS systems underlie thoughts and behaviors can guide clinicians in matching the delivery of empirically supported treatments with patients’ individual needs.

In the case of Cognitive Behavioral Therapy (CBT), which typically has a primary focus of seeking to limit maladaptive responses, examples and content may look quite different if the patient is more impacted by BIS-driven sensitivity to punishment cues versus BAS-driven sensitivity to reward cues. CBT may be tailored to help override catastrophizing and tolerate distress (i.e., a BIS-limiting strategy), or appropriately limit physical activity in the context of activity-rest pacing and short-term goal pursuit (i.e., a BAS-limiting strategy). In both examples, the treatment goal is to limit a thought or behavior, and the BIS-BAS information informs the rationale for how this might be accomplished. CBT also often includes strategies that reflect the Activate and Enhance components of the LA&E model; understanding how patients experience reinforcement for these activating behaviors and for re-engaging in valued activities may be more effective if the BAS-enhancing/rewarding treatment components are emphasized.

Motivational interviewing (Miller & Rollnick, 2013), a collaborative counseling style used to strengthen motivation and commitment to change often incorporated into pain treatment and rehabilitation settings more generally may also be informed by the BIS-BAS model. Awareness of BIS-BAS sensitivity can guide conversation to different emphases to support common change goals that are articulated in self-talk (e.g., “What are some of the ways pain has impacted your ability do the things you want to do in your life?” – a BIS-oriented question vs. “If pain didn’t limit you, what would you want to do in your life?” – a BAS-oriented question).

Similarly, Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 2012) focuses on teaching skills that encourage engagement in valued activities despite pain (i.e., behavioral activation – a BAS-oriented practice), and strategies to increase distress tolerance (a BIS-centered strategy that decreases sensitivity to punishment cues). An important additional consideration is that for individuals with higher BAS sensitivity, it may be particularly important to identify and target maladaptive behaviors that bring short term reinforcement, but may not ultimately support long term positive function. Finally, many mindfulness-based approaches, such as Mindfulness-Based Cognitive Therapy (Day, 2017) can be viewed as targeting both BIS and BAS sensitivity, by decreasing sensitivity to both BIS and BAS cues overall by cultivating a “stepping back” and engagement in a decentered, observer stance.

The BIS-BAS model may also inform rehabilitation treatments more broadly, outside of the context of formal pain treatments. For example, in individuals who present with excessive pain-contingent rest, understanding the degree to which this is influenced by BIS (i.e., via a goal to avoid expected discomfort and interpretation of pain as punishing) versus by BAS (i.e., via a goal to experience the rewards of solicitous responses from a spouse) may be managed by any member of an interprofessional team. The team itself can be oriented to capitalizing on BAS by increasing rewarding attention to healthy activation and other healthy behaviors and decreasing rewarding attention to maladaptive behaviors. The team may also address BIS by utilizing a time-contingent activity schedule that emphasizes an approach behavior (task persistence) and de-emphasizes avoidance behavior (stopping with onset of discomfort) (Fordyce, 1976). All of these treatment strategies and practices are highly compatible with the process of rehabilitation, which seeks simultaneously to maximize activity and participation (encouraged by BAS sensitivity) and reduce barriers to engagement (exacerbated by BIS sensitivity).

As we learn more about the role that BIS and BAS sensitivity play in patient function, as well as the specific treatments or treatment components that influence each together or separately, we will be better able to match patients to the treatments they may be most likely to benefit from, as proposed by the LA&E model. Patients high in both BIS and BAS sensitivity, for example, would be expected to be more responsive to interventions that target decreases in BIS than increases in BAS. On the other hand, patients low in BIS and BAS would be expected to benefit from treatments that target increases in BAS sensitivity than decreases in BIS sensitivity. As we learn more about these issues and become more effective in matching patients to interventions, overall improvements in response to treatment should be observed.

Limitations

This study has a number of limitations that should be considered when interpreting the findings. First, the sample was composed exclusively of Veterans receiving care in the VA who agreed to enroll in a clinical trial examining a group-based intervention for pain. The extent to which these findings generalize to non-Veterans, Veterans not receiving VA care, are unwilling or unable to participate in a trial, or are not experiencing sufficient pain to qualify for a trial are not known. The current findings need to be replicated in other samples and settings to help determine their generalizability. Second, the data used for the current analyses were cross sectional. As a result, we are not able to test for, or draw conclusions about, causal relationships between variables, or examine relationships over time. The extent to which BIS and BAS sensitivity have causal influences on functional outcomes, or vice versa, will require experiments that systematically and effectively target these for change, and that then determine the influence of changes in these variables on patient function. Finally, the magnitude of associations between BIS-BAS constructs and functioning was modest and the ability of BIS-BAS to predict clinically meaningful outcomes and facilitate clinically meaningful change remains to be demonstrated. That said, the study also had important strengths including a large sample size and a broader distribution of demographic factors (age, gender, race) and pain etiologies than is often seen in studies of Veterans.

Summary and Conclusions

Despite the study’s limitations, the findings provide important new information regarding the utility of the BIS-BAS model of chronic pain for understanding functional pain outcomes in a Veteran population reporting heterogeneous chronic pain. Importantly, the “brake pedal” of the BIS was found to have a larger effect than the “gas pedal” of BAS on both negative and positive pain outcomes; all else being equal, it may be more important to limit BIS than enhance BAS in Veterans with chronic pain in order to improve their function across different domains. Still, BAS sensitivity does appear to play an independent role, even if that role is less than that of BIS. Taken together, the current findings can be considered in light of previous and future research findings to help to inform more effective patient-treatment matching, and highlight the need for targeted interventions that address both BIS and BAS networks in individuals with chronic pain.

Impact and Implications.

This study provides support for the BIS-BAS model of chronic pain and suggests that behavioral inhibition and behavioral activation systems may make important, and unique, contributions to the functional impact of chronic pain. Results have practical implications for the development of pain-related treatments and the matching of specific treatment components to individual patient characteristics. Understanding the mutually-reinforcing interaction of behaviors, cognitions and emotions associated with each BIS and BAS systems could result in interventions with treatment targets that are more specific, efficient, and ultimately effective.

Acknowledgements:

This work was supported by the National Center for Complementary and Integrative Health (Grant # 1R01AT008336-01, awarded to Co-Principal Investigators Mark Jensen, Ph.D. and Rhonda Williams, Ph.D.) This work was also supported in part with resources and facilities at VA Puget Sound Health Care System and the University of Washington. The contents of this manuscript do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. This trial is registered in ClinicalTrials.gov (NCT02653664).

References

  1. Asmundson GJ, & Katz J (2009). Understanding the co-occurrence of anxiety disorders and chronic pain: state-of-the-art. Depression and Anxiety, 26(10), 888–901. doi: 10.1002/da.20600 [DOI] [PubMed] [Google Scholar]
  2. Bair MJ, Robinson RL, Katon W, & Kroenke K (2003). Depression and pain comorbidity: a literature review. Archives of Internal Medicine, 163(20), 2433–2445. doi: 10.1001/archinte.163.20.2433 [DOI] [PubMed] [Google Scholar]
  3. Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, & Hendrie HC (2002). Six -item screener to identify cognitive impairment among potential subjects for clinical research. Medical Care, 40(9), 771–781. doi: 10.1097/00005650-200209000-00007 [DOI] [PubMed] [Google Scholar]
  4. Campbell-Sills L, Liverant GI, & Brown TA (2004). Psychometric evaluation of the behavioral inhibition/behavioral activation scales in a large sample of outpatients with anxiety and mood disorders. Psychological Assessment, 16(3), 244–254. doi: 10.1037/1040-3590.16.3.244 [DOI] [PubMed] [Google Scholar]
  5. Carver CS, & White TL (1994). Behavioral inhibition, behavioral activation, and affective responses to impending reward and punishment: The BIS/BAS scales. Journal of Personality and Social Psychology, 67(2), 319–333. [Google Scholar]
  6. Cella D, Riley W, Stone A, Rothrock N, Reeve B, Yount S, … Group, P. C. (2010). The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008. Journal of Clinical Epidemiology, 63(11), 1179–1194. doi: 10.1016/j.jclinepi.2010.04.011 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Cook KF, Jensen SE, Schalet BD, Beaumont JL, Amtmann D, Czajkowski S, … Cella D (2016). PROMIS measures of pain, fatigue, negative affect, physical function, and social function demonstrated clinical validity across a range of chronic conditions. Journal of Clinical Epidemiology, 73, 89–102. doi: 10.1016/j.jclinepi.2015.08.038 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Dawu W, Chao H, Kaiting L, Lan S, Xiaohua P, & Dingqun B (2019). Pain correlates with social integration in individuals with traumatic spinal cord injury: A cross-sectional survey. Journal of Rehabilitation Medicine, 51(7), 506–512. doi: 10.2340/16501977-2565 [DOI] [PubMed] [Google Scholar]
  9. Day MA (2017). Mindfulness-Based Cognitive Therapy for Chronic Pain. Chichester, UK: Wiley. [Google Scholar]
  10. Day MA, Ehde DM, & Jensen MP (2015). Psychosocial Pain Management Moderation: The Limit, Activate, and Enhance Model. Journal of Pain, 16(10), 947–960. doi: 10.1016/j.jpain.2015.07.003 [DOI] [PubMed] [Google Scholar]
  11. Day MA, Matthews N, Newman A, Mattingley JB, & Jensen MP (2019). An evaluation of the behavioral inhibition and behavioral activation system (BIS-BAS) model of pain. Rehabilitation Psychology, 64(3), 279–287. doi: 10.1037/rep0000274 [DOI] [PubMed] [Google Scholar]
  12. Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, … Immpact. (2005). Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain, 113(1–2), 9–19. doi: 10.1016/j.pain.2004.09.012 [DOI] [PubMed] [Google Scholar]
  13. Eccleston C, & Crombez G (1999). Pain demands attention: a cognitive-affective model of the interruptive function of pain. Psychological Bulletin, 125(3), 356–366. doi: 10.1037/0033-2909.125.3.356 [DOI] [PubMed] [Google Scholar]
  14. Fordyce WE (1976). Behavioral methods for chronic pain and illness. St. Louis: Mosby. [Google Scholar]
  15. Gable SL, Reis HT, & Elliot AJ (2000). Behavioral activation and inhibition in everyday life. Journal of Personality and Social Psychology, 78(6), 1135–1149. doi: 10.1037//0022-3514.78.6.1135 [DOI] [PubMed] [Google Scholar]
  16. Gray JA (1990). Brain systems that mediate both emotion and cognition. Cognition and Emotion, 4(3), 269–288. [Google Scholar]
  17. Gray JA, & McNaughton N (2003). The Neuropsychology of Anxiety: An enquiry into the function of the septo-hippocampal system. Online 2008: Oxford Press. [Google Scholar]
  18. Hayes SC, Strosahl KD, & Wilson KG (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York, NY: Guilford. [Google Scholar]
  19. IOM. (2011). In Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): The National Academies Press. [PubMed] [Google Scholar]
  20. Jensen MP (2010). Measurement of pain In Fishman SM, Ballantyne JC, & Rathmell JP (Eds.), Bonica’s management of pain (4th ed.). Media, PA: Williams and Wilkins. [Google Scholar]
  21. Jensen MP, Ehde DM, & Day MA (2016). The Behavioral Activation and Inhibition Systems: Implications for Understanding and Treating Chronic Pain. Journal of Pain, 17(5), 529 e521–529 e518. doi: 10.1016/j.jpain.2016.02.001 [DOI] [PubMed] [Google Scholar]
  22. Jensen MP, Tan G, & Chua SM (2015). Pain Intensity, Headache Frequency, and the Behavioral Activation and Inhibition Systems. Clinical Journal of Pain, 31(12), 1068–1074. doi: 10.1097/AJP.0000000000000215 [DOI] [PubMed] [Google Scholar]
  23. Jensen MP, Turner JA, & Romano JM (1994). What is the maximum number of levels needed in pain intensity measurement? Pain, 58(3), 387–392. doi: 10.1016/0304-3959(94)90133-3 [DOI] [PubMed] [Google Scholar]
  24. Lai JS, Garcia SF, Salsman JM, Rosenbloom S, & Cella D (2012). The psychosocial impact of cancer: evidence in support of independent general positive and negative components. Quality of Life Research, 21(2), 195–207. doi: 10.1007/s11136-011-9935-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Miller WR, & Rollnick S (2013). Motivational Interviewing: Helping People Change (3rd ed.). New York: Guilford. [Google Scholar]
  26. Serrano-Ibanez ER, Lopez-Martinez AE, Ramirez-Maestre C, Esteve R, & Jensen MP (2019). The behavioral inhibition and activation systems and function in patients with chronic pain. Personality and Individual Differences, 138, 56–62. [Google Scholar]
  27. Takeyachi Y, Konno S, Otani K, Yamauchi K, Takahashi I, Suzukamo Y, & Kikuchi S (2003). Correlation of low back pain with functional status, general health perception, social participation, subjective happiness, and patient satisfaction. Spine (Phila Pa 1976), 28(13), 1461–1466; discussion 1467. doi: 10.1097/01.BRS.0000067091.88283.B6 [DOI] [PubMed] [Google Scholar]
  28. Watson D, Wiese D, Vaidya J, & Tellegen A (1999). The two general activation systems of affect: Structural findings, evolutionary considerations, and psychobiological evidence. Journal of Personality and Social Psychology, 76(5), 820–838. [Google Scholar]
  29. Wilkie R, Blagojevic-Bucknall M, Belcher J, Chew-Graham C, Lacey RJ, & McBeth J (2016). Widespread pain and depression are key modifiable risk factors associated with reduced social participation in older adults: A prospective cohort study in primary care. Medicine (Baltimore), 95(31), e4111. doi: 10.1097/MD.0000000000004111 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Williams RM, Ehde DM, Day MA, Turner AP, Gertz K, McCall A, … Jensen MP (2020). The Chronic Pain Skills Study: Protocol for a randomized controlled trial comparing hypnosis, mindfulness meditation and pain education in Veterans. Contemporary Clinical Trials. Advanced online publication. doi: 10.1016/j.cct.2020.105935 [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES