Cognitive intrusion of pain and catastrophic thinking independently explain interference of pain in the activities of daily living Mojtaba Talaei-Khoei a , Paul T. Ogink a , Ragini Jha a , David Ring b , Neal Chen a , Ana-Maria Vranceanu c, * a Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA b Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, TX, USA c Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA article info Article history: Received 27 December 2016 Received in revised form 19 March 2017 Accepted 13 April 2017 Keywords: Pain Pain interference Catastrophizing Cognitive intrusion ECIP PCS abstract Patients with musculoskeletal illness often report that pain interferes with their ability to engage in activities of daily living. Catastrophic thinking is consistently depicted as an important cognitive factor that hinders adjustment to pain. Current research has also shown that pain negatively impacts an in- dividual's ability to maintain attention on the task at hand. While a measure of the experience of cognitive intrusion of pain (ECIP) has been recently developed to quantify the extent of that impact, little research has explored this issue in everyday settings. This study tested the mediating roles of cognitive intrusion of pain and pain catastrophizing scale (PCS) on the association of pain intensity with pain interference in 142 patients with upper-extremity musculoskeletal illness. We found that both cognitive intrusion of pain (b ¼ 0.136, bootstrap SE ¼ 0.048, 95% BCa CI [0.052, 0.245]) and pain catastrophizing (b ¼ 0.114, bootstrap SE ¼ 0.044, 95% BCa CI [0.047, 0.221]) partly and independently mediated the relationship between pain intensity and pain interference. Although comparable, the mediation effect of cognitive intrusion of pain was slightly larger than that of pain catastrophizing (25.7%, bootstrap SE ¼ 0.094 vs. 21.5%, bootstrap SE ¼ 0.080). Results suggest that pain sensations can interfere with ac- tivities of daily living through two distinct mechanisms. A combination of traditional cognitive behav- ioral therapy and mindfulness skills training targeting both pain catastrophizing and cognitive intrusion has the potential to decrease pain interference and help patients return to normal healthy living in spite of acute or persistent pain. © 2017 Elsevier Ltd. All rights reserved. 1. Introduction Pain distracts attention from activities of daily living (Arnold et al., 2008; Attridge et al., 2015; Bennett et al., 2007). Pain negatively impacts task performance (Buhle and Wager, 2010; Crombez et al., 1996; Van Ryckeghem et al., 2012) particularly for complex tasks that require executive control (Moore et al., 2012). Pain automatically grasps attention from the task at hand, in both healthy individuals (Keogh et al., 2014) as well as those with acute (Gil-Gouveia et al., 2016) and chronic pain conditions (Eccleston, 1995). The emerging evidence of the impact of pain on attention has led to the development of the Experience of Cognitive Intrusion of Pain (ECIP) scale (Attridge et al., 2015) which captures the pro- cesses though which pain impacts attention and cognitions. The intrusion of pain onto cognition is theorized as occurring in three sequential stages (Eccleston and Crombez, 1999): an initial inter- ruption of a mental activity by pain and reorientation of attention toward pain, followed by pain becoming the center of attention and its dominance in mind and subsequent over focus and inability to disengage attention from the pain sensation (Van Damme et al., 2002, 2004). The ECIP is aimed at measuring the subjective experience of such intrusion rather than the processes composing the intrusion by focusing on the extent to which pain interferes with cognitions. Prior research has shown that pain catastrophizing is one of the most important cognitive factors associated with decreased func- tion in patients with acute and chronic pain (Das De et al., 2013; * Corresponding author. Department of Psychiatry, Behavioral Medicine Service, Massachusetts General Hospital, One Bowdoin Square,7th Floor, Boston, MA 02114, USA. E-mail address: avranceanu@mgh.harvard.edu (A.-M. Vranceanu). Contents lists available at ScienceDirect Journal of Psychiatric Research journal homepage: www.elsevier.com/locate/psychires http://dx.doi.org/10.1016/j.jpsychires.2017.04.005 0022-3956/© 2017 Elsevier Ltd. All rights reserved. Journal of Psychiatric Research 91 (2017) 156e163