At the IASP 2022 World Congress on Pain, taking place 19-23 September in Toronto, Canada, the International Association for the Study of Pain will present awards to honor the achievements of up-and-coming and further established investigators. Here, we chat with Dr. Lauren Heathcote, winner of IASP’s 2022 Ulf Lindblom Young Investigator Prize for Clinical Science.
Heathcote is a senior lecturer of Health Psychology in the Institute of Psychiatry, Psychology, and Neuroscience at King’s College London, UK. Her research focuses on how psychology impacts the physical symptoms of chronic pain, with the goal of creating more meaningful self-report assessments, as well as more effective pain treatments.
Here, Heathcote speaks with freelance writer Kayt Sukel about the concept of bodily threat in pain, how to better measure bodily threat in different pain populations, and how we can work backwards using these types of psychological concepts to develop more effective pain treatments. Below is an edited transcript of their conversation.
What first inspired you to pursue research in the pain field?
It was a bit of a happenstance as, I think, so many things are in life. I became interested in psychology on day one of university. I did my undergraduate degree and master’s degree in psychology, and was working as a research assistant in Jennifer Lau’s lab at the University of Oxford, UK. We were studying the psychological mechanisms of anxiety and depression in adolescents, and we were approached by a clinician at the hospital in Oxford who ran the pediatric pain service. He said, “I think the research you’re doing regarding kids with anxiety is relevant for the kids I see with persistent pain.” That was the first time I had thought about how psychology could be applied to better understand pain in these different health populations.
That was also about the point where I was figuring out what I wanted to do for my PhD. I remember Jennifer sitting me down and asking if I wanted to work on the anxiety stuff or the pain stuff. I thought the work in pain was really novel. We know much less about how the brain, how our psychology, might be relevant to our physical health experiences compared to our mental health ones. That’s what started me on this path.
Tell me a bit about the concept of bodily threat and why it is so important to understanding the pain someone may be experiencing.
I was lucky enough to have Chris Eccleston as a co-supervisor on my doctorate. All of his research is underpinned by this evolutionary, functional understanding of pain. It’s this idea that pain is a brain output that is designed to signal threat in order to promote certain behaviors to help get rid of the threat. I remember being quite struck by him describing pain in that way. I experienced a major illness as a child, and this evolutionary, functional model of pain really struck a chord with me. If you have a life-threatening illness, especially early in life, you likely experience pain as a part of that illness. From then on, forever onwards, pain will be a really salient signal of threat, especially as a potential recurrence of that illness or a latent effect of any treatment you had.
I started looking in the literature for studies that approached pain in this way in patients that had cancer or diabetes – these relapsing-remission conditions that are so common in healthcare. I found almost no evidence that people thought about pain this way in these patient populations. Instead, pain was discussed in a very biomedical way where pain is a consequence of surgery or some other aspect of the disease. For me, however, the idea that pain is a signal of threat is perhaps one of the most salient characteristics in these populations where people have had a major health event which ties pain to a danger to their body.
What are some of the challenges of trying to characterize that idea of bodily threat in self-reported measures of pain?
There are challenges for both researchers and clinicians. As researchers, to really gain a comprehensive understanding of how the perception of threat relates to pain experiences, we need to be able to measure perception – how people perceive pain as threatening at a high level. So far, some of the work we’ve been doing, when we measure how threatening the pain may be, we do in quite specific ways. Examples include asking if someone is worried about what their pain means, whether they think it will last forever, or if their pain means there’s something really wrong with the affected part of their body. We need to look at specific illness cognitions to understand what exactly is threatening for that person in a particular population. What I’ve been working on for the last few years is developing a measure that taps into that process more generally so we can use it with people in different contexts. We can use the same measure in people with chronic non-cancer pain, with cancer survivors, or people with inflammatory bowel syndrome. By using one standard measure, we can study how this one mechanism may be relevant to lots of different people with lots of different conditions.
Clinically, we may need a different approach. Instead of one measure that can be used across a wide variety of populations, the opposite is needed. Some of the work we are doing in our cancer survivor studies shows that it’s very important to ask specifically about what patients find threatening about their pain. We’ve been doing a lot of work in both adult and pediatric cancer survivor populations, as well as a recent survey with oncologists, to understand how clinicians talk to patients about this. We are learning that a useful starting point when clinicians talk to a patient living with pain is to directly ask how that person may be interpreting that pain. What do you think that pain means for your body? What are you worried about? What comes to mind when you first experience that pain? That way, clinicians can tap into the specifics about what might be threatening about that pain so they can target those specific cognitions through education or other means.
How can the development of improved self-reported measures of pain help us better understand it – and, by extension, better treat it?
I’ve been thinking a lot recently about the NIH Research Domain Criteria (RDoC) framework, and the idea that our physical and mental health conditions do not necessarily fall into distinct categories. The symptoms overlap, and I think the same is true with chronic health conditions, like chronic pain and chronic fatigue. Instead of studying these things as separate entities, it’s important to find shared mechanisms that might help explain the existence of these conditions, as well as any comorbidities. I was struck that in order to have a specific construct like bodily threat monitoring, which is what we are working on right now to have included in this RDoC framework, you need to show a biomarker of that construct.
You need to show that bodily threat is related to some sort of pattern in the brain, or that it is associated with something going on in the body. A neuroscientist might want to find a pattern in the brain that will predict if someone responds to treatment, but if we can understand and develop a strong theory around the psychological mechanism – you know, what is the conscious experience of the human – and whether or not they’ll respond to treatment, we could start to work backwards to find the appropriate biomarker. We think bodily threat monitoring is the kind of psychological marker that might predict worse outcomes or may indicate that someone is more likely to transition from acute to chronic pain. We can use that to ask ourselves what we know about the brain, and how it pays attention to the body, and look for corresponding neural mechanisms to try and map this experience to a biomarker. Working backwards, we may find new ways to improve clinical outcomes for these patients.
How did it feel to learn you won the Ulf Lindblom Young Investigator Prize for Clinical Science?
It was a surprise! I honestly didn’t think I would win the award because there are so many fabulous people doing so many wonderful things in this field, but I’m so grateful to receive this recognition. With so much instability in academic careers, particularly for early-career researchers, having these kinds of concrete recognitions is important.
What do you hope people will take away from your talk at this year’s World Congress on Pain?
I’ll be talking about this shared evolutionary, functional model of pain as a signal of threat, and if we can start to model that across these different disciplines, like clinical and basic science, I think we can advance the field. In psychology, we’re starting to do that by creating better self-report questionnaires, but in animal neuroscience models, this model might inspire researchers to start thinking about what behaviors relate to the perception of threat. How can we model and measure this concept there? I believe we could open up a new path for understanding pain, not necessarily as this felt experience, but as sort of a functional, protective thing. If we can pull together pieces of evidence from psychology, from neuroscience, and other fields that align with this functional perception of pain as a signal of bodily threat, we will be well suited to identify novel interventional approaches in the future. Those may be pharmaceutical treatments that directly impact the chemicals in our brain, or may be behavioral interventions that can target this specific mechanism.
Kayt Sukel is a freelance writer based outside Houston, Texas.