Frontiers in Cognitive Psychology

2016; 1(3): 33-42

http://www.sciencepublishinggroup.com/j/fcp
doi: 10.11648/j.fcp.20160103.14

Cognitive Impairment and Mental Inflexibility in Burn

Trauma
Imtiaz Hussain1,*, Dr Amara Gul2, Muhammad Azhar3, Mahdi Hayat Khan4, Sadia Zafar5
1
Department of Applied Psychology, Government Postgraduate Degree College Jhang, Punjab, Pakistan
2
Department of Applied Psychology, Islamia University Bahawalpur, Punjab, Pakistan
3
Head of Department Geography, Government Degree College Shorkot, Punjab, Pakistan
4
Vice Principal Government Postgraduate Degree College Jhang, Punjab, Pakistan
5
Psychologist in Punjab Jail Department, Punjab, Pakistan

Email address:
[email protected] (I. Hussain)
*
Corresponding author

To cite this article:

Imtiaz Hussain, Dr Amara Gul, Muhammad Azhar, Mahdi Hayat Khan, Sadia Zafar. Cognitive Impairment and Mental Inflexibility in Burn
Trauma. Frontiers in Cognitive Psychology. Vol. 1, No. 3, 2016, pp. 33-42. doi: 10.11648/j.fcp.20160103.14

Received: December 6, 2016; Accepted: December 22, 2016; Published: January 17, 2017

Abstract: The current study examined task switching in burn patients with pain and healthy individuals without pain.
Participants performed face categorization tasks and switched between emotion and non-emotion (i.e. age) features among
faces. There were three main results of interest: First, burn patients with pain showed impaired task switching ability than
healthy pain-free individuals (i.e., greater switch costs). This result may be attributed to reduced executive resources among
burn patients with pain. Second, emotion decisions to faces yielded lower switch cost than age decisions among burn patients.
In contrast, such asymmetries were not observed among healthy controls. It is argued that the different pattern of results reflect
greater attentional weightage to emotion than the non-emotion attribute of the faces among burn patients with pain. Third, burn
patients with pain had recurrent pain-catastrophic thoughts than healthy controls. Pain-related catastrophizing scores predicted
task switch costs. It is argued that the efficient task switching benefit from lower level of pain catastrophizing.
Keywords: Cognition,Pain, Task Switching, Emotion, Burn, Pain Catastrophizing

relevant (new) task-set rule [33]. Switch cost indicates the

1. Introduction efficiency to engage the relevant task rule and inhibit the
The concepts of cognition and pain are connected due to irrelevant task rule on the current trial. Thus, task switching
the fact that pain is a subjective experience which has a simply involves an activation of the relevant rule [44] and
cognitive-evaluative component involving recall of past extra inhibitory processes to minimize interference from
experiences and active decision making [38]. In the current competing "task-sets" [33].
study, we aim to assess the relationship between pain and An "alternating run" paradigm [42] is the popular task
executive function (i.e., a subset of cognitive domains). Task switching paradigm as it avoids confounds in earlier task
switching is an executive function which involves the switching paradigms [23]. In an alternating-run, switch costs
cognitive flexibility to shift attention from one task-set to are measured within block (reaction times on alternate/switch
another enabling the individual to rapidly and efficiently trials minus reaction times on non-alternate/repeat trials) as
adapt to different situations. A task-set is defined as an the subjects are required to perform two or more tasks in an
operative intent to perform a task, which requires an alternate order (AABBAABB...), to avoid overall differences
individual's attention to be in accordance with specific in the number of tasks being performed. In experimental
operations demanded by the task. When the task switches paradigm of Jersild (1927) for instance, participants are
and the response has to be made on the basis of changed required to perform an alternate run block, which carries two
task-set rule [35, 42] a cost on reaction times (i.e., switch tasks while in a pure run, only one task is performed. Studies
cost) can arise from the subsequent delay in selecting the inducing experimental pain demonstrated that pain disrupted
34 Imtiaz Hussain et al.: Cognitive Impairment and Mental Inflexibility in Burn Trauma

cognitive performance and executive control, for example dimensions guides attention and action during the
adults under thermal heat pain showed impaired ability to performance of a cognitive task [48]. The attention to
perform executive control functions which involved affective and pain-related information depends on the
switching and goal-directed planning [26]. Likewise, patients motivation level to perform the current goal [43, 54]. The
experiencing pain showed poorer performance on a number activated representations in working memory guide the
of categories and non-perseverative errors as assessed by attention to choose a preferred goal in situations where none
Wisconsin card sorting test (test of executive function) than of the goals is contingent upon a reward. On a
healthy individuals [58]. neuroanatomical level, cognitive control system which is
Intense pain experience was found to be associated with regulated by dorsolateral prefrontal cortex (DLPFC) also
decreased performance on a number-letter switching task [25] depends on the activity of the anterior cingulate cortex
and cognitive flexibility as assessed by the trail making and (ACC). ACC is involved in the emotional control and is
grooved pegboard test [61]. Using a task switching paradigm, connected both to the DLPFC and the limbic system [17].
when participants switched and repeated between shape The reduction in the hippocampal volume and the weaker
(square/triangle), color (pale/dark grey) and orientation ACC activity in patients with persistent pain [39, 3] play an
(vertical/diagonal) decisions to the target stimulus, it was influential role in memory, emotion, and attention deficits
observed that independent of the intensity, pain interfered with commonly observed in such patients [1].
the performance on a subsequent task. Such effects were larger Pain interrupts an ongoing activity [15]. Chronic pain
when participants switched to another task than when they patients perform less stable than healthy individuals in
repeated the same task [56]. It has been suggested that there is multitask environment [56]. An anatomical stage model of
a relationship between executive functioning and pain affect as pain-contingent interruptions suggest that pain captures
participants with good inhibition and working memory attention and suspends an ongoing activity by limiting the
abilities experience the cold pressor task as less stressful and working memory capacity for task retrieval/resumption. As
unpleasant [60], thus inhibition abilities of an individual are pain relief becomes prioritized goal, task related information
important to focus on a task rather than the pain [59]. is resumed after a break. This resumption lag is related to
Pain disrupts attention and cognitive performance. Higher- switch costs which reflect the time taken to disengage from
order attentional tasks (e.g., n-back and attentional switching one task to another task [19].
task) are particularly susceptible to pain interference [37] due Several studies suggest that cognitive performance is
to the demand to process multiple cues while exerting control linked with catastrophizing and pain beliefsbut not pain
over attentional deployment [36]. During attentionally intensity [18]. There are several predictors of an individual's
demanding situations, deficient cognitive control over response toward a painful experience such as attentional and
attentional allocation has been observed among chronic pain emotional processes [52], avoidance behavior [29, 32], hyper
patients [15] particularly an involuntary attentioanl shift vigilance [34] and catastrophizing [28]. Pain catastrophizing
toward the sensory and pain affective information[7, 41, 55] is conceptualized as an exaggerated negative "mental set"
for review). Such deficits are associated with difficulty in experienced during an actual or anticipated pain experience
disengaging attention from pain-related stimuli rather than [50, 51]. People with high level of pain catastrophizing
hyper vigilance [46, 11]. Experience of pain rather than experience more difficulty to disengage attention away from
duration, is the primary indicator of pain-related biases [20]. pain when it is perceived as threatening [54]. Catastrophizing
The attentional shift toward painful facial expressions is enhances somatosensory information and produces
positively influenced by high fear of pain/ (re) injury [27]. attentional interference [8]. Even in pain-free individuals,
Pain chronicity is linked with limited cognitive flexibility, participants with high level of catstrophizing display retarded
memory capacity and sustained attention [40, 2], due to the disengagement from pain, in contrast participants with low
deficient allocation of resources rather than the attentional level of catastrophizing show intact disengagement from pain
capacity. Studies investigating visual event-related potentials [53]. Pain catastrophizing mediates the relationship between
suggest that the amount of attentional resources invested in a pain intensity and psychological states such as depression
task is deficient in pain patients (i.e., decreased amplitude for [62]. It is an important cognitive factor which influences the
probe stimuli with increasing task load; [57]. One possible outcome following chronic pain treatment [5, 6]. The
mechanism for observed cognitive impairment among pain reduction in pain catastrophizing mediates the outcome of
patients is that pain contests with other attention-demanding physical and cognitive behavioral treatment in chronic low
stimuli for limited cognitive resources [15, 18] and impairs pain patients [47].
top-down attentional control mechanisms. The disruption in The Present Study
attentional control mechanisms filters out task-irrelevant Our first objective in this study was to compare switching
stimuli. As a result, the performance on a cognitive task is abilities between burn patients with pain and healthy
impaired [30]. individuals. We hypothesized that burn patients with pain
The Stimulus dimension which gain prioritization activates would show impaired task switching ability (i.e., higher
its' representation in memory, these representations remain switch costs) as compared to pain-free healthy individuals.
active in the situations when their processing is goal- Attention to pain and affective information depends on
irrelevant [4, 13]. The automatic processing of such stimulus pursuit of concurrent goals e.g., [43, 54]. We expected that
 Frontiers in Cognitive Psychology 2016; 1(3): 33-42 35

participants with pain would show a commitment to the 2. Method

emotion rather than the age task. In this case, a larger switch
cost for the age task would arise due to the greater attentional 2.1. Sample
weightage to emotion rather than a non-emotion task. The From March until September 2013, 50 burn patients (age
third aim was to examine whether pain-related thoughts range 18-45 years, M=28 years, SD=4.47) with
could predict task switching abilities among burn patients normal/corrected vision and right handedness volunteered to
with pain and pain-free healthy individuals. Based on the participate in the study from burn units of the General and
finding that pain-related thoughts produce attentional Allied hospital, Jhang (see Table 1).
interference [8], we expected that pain catastrophizing would
predict task switching abilities.
Table 1. Demographic and clinical characteristics for 50 patients with burn injures and 50 healthy controls.

Variables Patients (n=50)% Control(n=50) %

Gender
Male 25 50% 25 50%
Female 25 50% 25 50%
Age (years)
18-25 18 36% 19 38%
26-35 27 54% 27 54%
36-45 3 6% 2 4%
BSA (%burn) Level
10%-14% Mild 50 100%
15%-24% Moderate - - - -
25%-34% Severe - - - -
>34%Very severe - - - -
Type of burn
Flame 23 46% - -
Scaled 13 26% - -
Electrical 7 14% - -
Chemical 7 14% - -
Pain intensity
1%-3%mild 20 - -
4%-6% moderate 10 - - -
7%-10% severe 20 - - -
0%no pain - - - -
BSA (Burn Surface Area)

Burn patients were selected according to the following 24 faces were old (elderly people 55-65 years old). Faces
criteria: i) burn rate 10-34% causing no disability (as portrayed neutral and happy (smiling: teeth obvious)
assessed by medical doctors) ii) burn injury on the chest, expressions. Among forty-eight images, 12 faces were of
abdomen, lower limbs, and thigh whereas patients with the young boys, 12 images were of young girls, 12 faces were of
injury on head, face, neck and upper limbs were excluded iii) old men and 12 images were of old women. All pictures were
No history of psychological disorder as self-reported iv) no in bitmap image size of 243, standardized on 4x4 inches/243
history of medical disease as assessed by clinical observation KB, 288 x 288 pixels, bit depth 24 with white background.
v) no use of oral medication vi) having at least mild pain Faces were presented in upright position and were pictured
from the 1st to 3rd day of the injury. 50 healthy individuals while looking in the lens. In the pilot study, participants were
(age range 19-42 years, M=25 years, SD=4.00) with asked to rate facial expression of emotions in
normal/corrected vision and right handedness were recruited photographs:How would you describe the salience of happy
from the Islamia University of Bahawalpur by an emotion a scale from 1 to 10' (1=very poorsalience,
advertisement for the study. The inclusion criteria for healthy 10=excellent salience). Selected photographs had mean
participants were: i) no history of medical and psychiatric (standard deviation) ratings: salience {happy 8.00 (0.81)},
disorder as self-reported ii) no use of oral medication iii) no based on a sample of 50 participants from both groups with
pain. an inter-rater reliability of 0.80. Apparatus, Display and
Computer Task: The experiment was programmed in E-prime
2.2. Materials software [45] and it was presented on the 16 inches laptop
2.2.1. Task Switching Experiment screen. The experiment was viewed with a comfortable
Experimental Stimuli: The experiment was designed with distance of 60 cm approximately. The display for each trial
48 colored photographs as experimental stimuli in task consisted of the presentation of a fixation cross (+) in center
switching paradigm [42]. Of the total 48 facial images, 24 of the screen for 1000 millisecond (ms), followed by a blank
pictures were of young adults (22-30 years of age) whereas screen for 1000 ms, then the face appeared.
36 Imtiaz Hussain et al.: Cognitive Impairment and Mental Inflexibility in Burn Trauma

Figure 1. Examples of the Stimuli used in the Task Switching Experiment.

The task of the participants was to decide emotion and age which consists of 13-items and three subscales: rumination,
of the face. Faces were exhibited on the laptop screen until helplessness and magnification. PCS is a measure of pain
the response was recorded. Trial Configuration: A total of related catastrophic thoughts. The total score ranges from 0-
241 experimental trials were designed. Trials were presented 52, the higher score represent higher pain catastrophizing
in an alternate-run EEAAEEAAEEAA throughout the [52]. For this study, PCS was translated into Urdu language
experiment (E=emotion and A=age task). Of 241 trials, the using back translation procedure. The translated version was
first trial did not carry a switch. The remaining 240 trials administered to burn patients and healthy controls (N=100)
were equally divided into emotion (120 trials=60 switch; 60 with an interval of 1 week. The test-retest reliability was high
repeat) and age task (120 trials=60 switch; 60 repeat. The for the translated version (r=.87, p<0.001). Participants were
task on each trial was cued by the fixed back ground color. asked to reflect upon their past painful experience, and
Blue color was used as a cue to perform emotion task while indicate the degree to which they experienced each of the 13
black color served as a cue for age task. Tasks were thoughts or feelings when they experienced pain, on a 5-
completely counter balanced across participants such as half point scale: (0) not at all (1) to a slight degree (2) to a
of the participants started the experiment with emotion task moderate degree (3) to a great degree (4) all the time.
and the other half performed age task first. On each trial, a
face was presented. Participants were asked to decide 2.2.3. Numeric Rating Scale
emotion (i.e., whether the face was happy/neutral) or age of As part of the routine care, all patients admitted to the burn
the face (young adult/old). The responses were made by units were asked to rate their pain intensity on each day
pressing fixed keys on the keyboard. The following keys following the injury. Numeric rating scale (NRS) was used to
were fixed on the keyboard of the laptop: Young adult=1, assess the level of pain on the 1st, 2nd and 3rd day following
old=2, Happy=3, and neutral=4. The keys were pressed by the injury and the current level of pain at the time of testing
the right hand with the first finger placed on 1 and small conducted on the 4th day of the injury. NRS is a popular
finger on 4. measure for evaluation of pain intensity in research and
clinical practice. According to the severity of pain, the patient
2.2.2. The Pain Catastrophizing Scale assigns a number from 0 to 10 [22]. The levels of pain are
The Pain Catastrophizing Scale (PCS) is a self-report scale described as no pain=0, mild pain=1-3, moderate pain=4-6,
 Frontiers in Cognitive Psychology 2016; 1(3): 33-42 37

severe pain 7-10 [22]. This scale has high test-retest procedure. They were told that it was a reaction time experiment
reliability [21]. and they must perform quickly without sacrificing accuracy.
After completion of the task switching experiment, they rated
2.2.4. Depression Anxiety Stress Scale their thoughts on pain catastrophizing scale [51]. Finally, they
The Urdu version of the Depression Anxiety Stress scale were debriefed and thanked for their participation.
(DASS) was used as a screening device [63]. The DASS is 42-
items self-report inventory which measures depression, anxiety
and stress. It has three subscales (i) Depression (ii) Anxiety 3. Results
and (iii) Stress. Each subscale consists of 14 items. Each item 3.1. Reaction Times
is rated from on a 4-point Likert type scale (0-3; 0=always
false to 3=always true). The administration time is Reaction times (RTs) for each participant were analyzed.
approximately 15 minutes. It is suitable to assess individuals Response times (RTs) lower than 100 ms and higher than 2.5
with age range from 17 to 70 years. Depression scale measures standard deviations above each participants individual mean
lack of interest, dysphonia, hopelessness, self-deprecation, RT wereconsidered as outliers and excluded (2.00%). RTs on
devaluation of life. The Anxiety scale assesses situational the first trial and incorrect trials (wrong response) were
anxiety, autonomic arousal, subjective experience of anxious excluded from the RT analyses (5.10%). Effect sizes were
affect and skeletal muscle effects. The Stress scale evaluates measured with 2 (.02=small;.13=medium;.26=large) and
the difficulty in relaxation, non-chronic arousal through Cohen's d (.20=small;.50=medium;.80=large) for independent
intolerant and bad tempered, nervous arousal and being easily samples [9, 10]. Switch costs were calculated by subtracting
upset. Scores on the depression scale are categorized into mean RTs on repeat trials (current trial is the same task) from
normal=0-9, mild=10-13, 14-moderate=20, severe=21-27 and mean RTs on switch trials (current trial is the other task). Mean
extremely severe=28 & above. For anxiety, scale scores are RTs were submitted to a repeated measures analysis of
categorized as: 0-7=normal; 8-9=mild; 10-14=moderate; 15- variance (ANOVA) with trial (switch versus repeat) and task
19=severe; 20 and above=extremely severe. For stress, scale (emotion versus age) as within subject and group (burn
scores are interpreted as: normal=0-14; mild=15-18; patients versus controls) as between subject factors. The main
moderate=19-25; severe=26-33; and extremely severe=37 & effect of trial was significant F (1, 98)=309.00, p<0.001,
above. DASS has an excellent internal consistency and sound 2=.75, switch (M=1462 ms) repeat (M=765 ms). There was a
correlation with other similar instruments [31]. significant effect of group F (1, 98)=47.00, p<0.001, 2=.32,
Burn patients (M=1353 ms) controls (873 ms). The effect of
2.2.5. Generalized Anxiety Disorder-7 task was not significant F (1, 98)=0.81, p=0.37, 2=.00, Age
Urdu version of Generalized Anxiety Disorder-7 (GAD-7) (M=1116 ms) Emotion (1111 ms). The interaction between
was used to screen participants with generalized anxiety trial x task was significant F (1, 98)=23.08, p<0.001, 2=.19.
disorder. GAD-7 consists of seven items and was developed to A larger switch cost for age decisions than the emotion
measure generalized anxiety. Participants were instructed to decisions was observed t (99)=4.15, p<0.001, age (M=719
indicate how often they had been concerned with the symptoms ms) emotion (M=674 ms). To examine whether these effects
over past 2 weeks. 0=not at all; 1=several days; 2=more than interact with emotional salience of the faces, we performed a
half of the day; 3=nearly every day. The scale consumed less separate ANOVA with factors being trial (switch versus
than 2 minutes to be completed. The entire score for the seven repeat), task (emotion versus age) and emotional salience
items ranges from 0-21 and cut-points are 5, 10, and 15 to screen (switch: current trial is the other salience versus repeat:
mild, moderate, and severe anxiety respectively. It has good current trial is the same salience) as within subject factors.
internal consistency and test-retest reliability [49]. The interaction between trial x task x salience failed to reach
2.3. Procedure the level of significance F (1, 99)=.00, p=.96, 2=.00,
Figure, 2a, 2b. There was a significant interaction between
The study received approval by the board of studies of the trial x group F (1, 98)=26.03, p<0.001, 2=.21,
Islamia University of Bahawalpur. After signing the written
informed consent form, participants rated their pain intensity on
the 1st, 2nd and 3rd day of the injury (NRS; [22]. These pain
ratings were averaged across from the 1st-3rd day of the injury.
On 4th day of the injury, participants with at least mild pain
(averaged across from the 1st-3rd day) were invited to
participate in the study. Participants with injury on face, neck,
upper limbs were not included in sample in order to ensure that
the physical condition of patients did not affect the task
performance. They were screened for generalized anxiety
(GAD-7; [49], depression and stress DASS; [31]. Participants
rated their pain intensity on 4th day of the injury (see Table 1)
and they were given a description of the experimental Figure 2a. Mean reaction times (ms) on switch and repeat trials for the age
and emotion task.
38 Imtiaz Hussain et al.: Cognitive Impairment and Mental Inflexibility in Burn Trauma

Figure 3a, 3b, this interaction was decomposed by

submitting trial (switch versus repeat: within subject factor)
and task (emotion versus age: within subject factor) to
separate repeated measures analysis of variance for each
group. For burn patients, the main effect of trial was
significant F (1, 49)=203.10, p<0.001, 2=.80. The effect of
task was not significant F (1, 49)=1.53, p=.22, 2=.03. The
interaction between trial x task was significant F (1,
49)=43.10, p<0.001, 2=.46. The switch cost for age
decisions was larger than emotion decisions t (49)=6.56,
p<0.001, d=.22; age (M=950 ms) emotion (M=849 ms). For
control group, the main effect of trial was significant F (1,
49)=106.05, p<0.001, 2=.68.
Figure 2b. Mean reaction times (ms) on switch and repeat trials for burn The main effect of task was not significant F (1, 49)=0.18,
patients and controls. p=0.67, 2=.00. The interaction between trial x task was not
significant F (1, 49)=0.81, p=0.37, 2=.01. There was no
Figure 2a, 2b, the switch costs were larger for burn significant difference between the switch cost for age and
patients than the healthy control groupt (49)=6.00,p<0.001, emotion decisions t (49)=0.90, p=.37, d=.02; age (M=489
d=1.03 burn patients (M=899 ms) controls (M=494 ms). ms) emotion (M=499 ms). For emotion decisions, RTs were
Burn patients performed slower on switch t (49)=7.49, slower for burn patients than control group on switch t
p<0.001 and repeat trials t (49)=4.04, p<0.001) than healthy (49)=7.26, p<0.001, d=1.44 and repeat t (49)=4.19, p<0.001,
control group. The interaction between task x group failed to d=.22 trials. Similarly, for age decisions, burn patients
reach the level of significance F (1, 98)=1.68, p=0.19, performed slower on switch t (49)=8.00, p<0.001, d=1.58
2=.01. There was a significant higher order interaction and repeat t (49)=3.84, p<0.001, d=.86 trials.
between trial x task x group F (1, 98)=34.28,p<0.001,
2=.25. 3.2. Errors

Error data for each participant were analyzed. Errors for

the first trial were not included in the analysis. Subsequently,
mean errors were submitted to the repeated measures
analysis of variance (ANOVAs) with factors as trial (switch
versus repeat: within subject), task (emotion versus age:
within subject) and group (burn patients versus controls:
between subject). There were significant main effects of trial
F (1, 98)=17.16, p<0.001, 2=.14; group F (1, 98)=13.16,
p<0.001, 2=.11; task F (1, 98)=6.00, p<0.05, 2=.05. Errors
were larger on switch than on the repeat trials (M=.03
vs..02). Errors were less on the age than the emotion task
(M=.02 vs..03). The experimental group had larger errors
than the control group
(M=.03 vs..01). There was a reliable interaction between
Figure 3a. Mean reaction times (ms) on age and emotion task for burn trial x task F (1, 98)=5.31, p<0.05, 2=.05. There was a
patients.
reliable interaction between trial x group F (1, 98)=6.24,
p<0.01, 2=.06. The interaction between task x group was
not significant F (1, 98)=0.87, p=.35, 2=.00. The higher
order interaction between trial x task x group was not reliable
F (1, 98)=0.00, p=.96, 2=.00. Pain-related thoughts and task
switching Pairwise comparisons showed that burn patients
had frequent pain-related catastrophic thoughts than healthy
group t (49)=21.26, p<0.001 (M=42.66, SD=10.78 vs.
M=11.98, SD=2.91). In addition, burn patients had higher
scores than the control group on three subscales of the PCS:
rumination t (49)=15.50, p<0.001 (M=14.10, SD=4.07 vs.
M=5.08, SD=1.19); helplessness t (49)=21.00, p<0.001
(M=19.84, SD 5.64 vs. M=4.22, SD=1.95); and
magnification t (49)=12.33, p<0.001 (M=8.72, SD=3.44 vs.
M=2.68, SD=0.97).
Figure 3b. Mean reaction times (ms) on age and emotion task for controls. A regression analysis was run with switch costs (i.e.,
 Frontiers in Cognitive Psychology 2016; 1(3): 33-42 39

difference between RTs on switch and repeat trials) as attention is required to manage dual task-sets. Paying more
dependent variable and pain catastrophizing as independent attention to emotion can be seen in the perspective of limited
variable. The analysis achieved a significant result F (1, attentional resources in patients with pain. Due to the limited
99)=74.47, p<0.001, R2=0.43. Hence, the independent attentional resources, patients with pain prioritized the
variable explained almost 43% of the variance of the switch emotion task-set and experienced difficulty disengaging
costs. Standard regression coefficients showed that pain attention from emotion decisions. Attention is crucial for
catastrophizing scores, =0.65, t=8.63, p<0.001 made management of multiple goals. Individuals often prioritize
positive contribution toward the explanation of switch costs. one goal in real life situations, whereas real life situations
When pain severity was controlled, significant partial demand processing of more than one goal [24]. The greater
correlation between pain catastrophizing scores and switch attentional weightage to emotion than age decisions can be
costs was found (r=.57, p<0.001). explained in framework of the visual attention theory [40].
The attentional weightage reflects the activation of goal
4. Discussion representations in working and long term memory. The
stimuli matching to the active representations in the
This study examined the role of pain in task switching environment are selected to pay more attention [48].
among burn patients with pain and pain-free healthy The contents of working memory guide the allocation of
individuals. This was assessed using task switching paradigm attention, in turn biasing the top-downmechanism. As a
in which participants with pain following burn injury and result, representations of the preferred stimulus dimension in
pain-free individuals switched and repeated between face long term memory are activated [12, 14].
categorization tasks. Tasks were presented in an alternating- When the preferred dimension of the stimulus is
run where participants made emotion and age decisions to maintained in the working memory, cortical representations
faces. We were interested in the effect of pain on the remain active through top down modulations mediated by the
efficiency switching between emotion and a non-emotion prefrontal cortex [17]. These activations provide a
task. Results showed that switching abilities were impaired in competitive advantage for the dimension leading to its'
patients with pain. The switch cost was larger for patients attentional allocation and suppression of the other stimulus
with pain than pain-free individuals. Patients with pain dimension [14]. Our results depicted that emotion dimension
performed slower on both types of trials when the task was among faces probably had more relevance to activated
changed and repeated as compared to healthy individuals. representations among patients with pain than facial age.
First we discuss the findings related to the role of pain in These activations remain active when there was a need to
impaired task switching performance. This result is reconfigure the age task. The activation of the emotion task-
consistent with previous studies showing that performance on set and the suppression of the age task-set produced larger
measures of executive function was deficient in individuals switch cost among patients with pain. On a neurofunctional
with pain, for instance patients with pain performed poor on level, pain is associated with weaker ACC (brain area
Wisconsin card sorting test [58], number-letter switching task responsible for emotional control) activation [17]. The larger
[25], trail making and grooved pegboard test [61] and shape, switch cost for the age task can be seen in the perspective of
color and orientation switching task [56]. The impaired goal weaker emotional control. Once the emotion-task was active,
directed planning and deficient switching effects were also it was harder for patients with pain to inhibit its' activation
found under experimentally induced pain [26]. Of further than healthy individuals.
interest is the finding that switching performance interacted A further aspect of the task switching relates to pain
with task among patients with pain. catastrophizing. Based on previous studies, we expected that
There was a larger switch cost for age than emotion pain-related thoughts could predict task switching abilities
decisions among patients with pain. This result depicted that among patients with pain and pain-free individuals. This
the attention to more salient property (i.e., emotion) of the prediction was supported by our results. Level of pain
face delayed age decisions. In contrast, such asymmetries catastrophizing determined attentional control from pain-
were absent among pain-free individuals. Previous studies related stimuli in both patients with pain and pain-free
demonstrated a deficient control over attentional deployment individuals [53, 54].
among patients with pain. During the performance of higher- People with high level of pain catastrophizing experienced
order attentional tasks such as n-back and attentional more difficulty to disengage attention away from pain. Our
switching task, participants with chronic pain showed a results showed that pain catastrophizing determined
failure in processing of multiple cues [37, 36, 15] particularly individual differences in task switching abilities. Higher level
an involuntary attentioanl shift toward pain affective of pain catastrophizing predicted higher task switching
information [7, 41, 55] for review. These attentional biases difficulties. Patients with pain reported higher level of pain
can be explained in terms of the deficient allocation of catastrophizing than healthy individuals. Catastrophizing
attentional resources to the competing task [57]. Our results causes poor attentional control [8].
depicted that the attention was paid to decisions relevant to The deficit in attentional control among pain patients
the more salient attribute of faces (i.e., emotion), therefore might have contributed towards switching impairments
the age decisions suffered. In the task switching experiment, among patients with pain. To our knowledge, these results for
40 Imtiaz Hussain et al.: Cognitive Impairment and Mental Inflexibility in Burn Trauma

the first time depicted that pain-related thoughts play an [2] Attal, N., Masselin-Dubois, A., Martinez, V., Jayr, C., Albi, A.,
important role in predicting the task switching performance. Fermanian, J., Bouhassira, D. etal. (2014). Does cognitive
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Emotion attribute among faces appears to be rather more surgical cohort. Brain, 137(3), 904-917.
motivational which inhibits the accessibility of othergoal
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the individual for transforming the intentional status into Acute and persistent pain modulation of attention-related
anterior cingulate fMRI activations. Pain, 113, 172-184.
action. Emotion is encoded as a commitment marker which is
tagged to the representation of the activity and in turn serves [4] Bundesen, C. (1990). A theory of visual attention.
as an internal context cue which ultimately biases the Psychological Review, 97, 523-547.
cognitive system (attentional/retrieval process) and builds-up
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and their role in attention. Proceedings of the National
pain can be improved with training. A possible limitation of Academy of Sciences, USA, 93, 13494-13499.
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cognitive neuroscience of visual attention. Philosophical
The authors wish to thank the Dr. Amara Gul for her Transactions of the royal society of London B, 353,1307-
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inspiration regarding this paper and life as a researcher,
particularly thankful to her for giving me the opportunity to [15] Eccleston, C., Crombez, G., Aldrich, S. & Stannard, C.
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Akbar kareem for technical assessment. Psychol Bull, 125, 356-366.

[17] Gray, J. R., Braver, T. S., &Raichle, M. E. (2002). Integration

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