Superior Analgesic Effect of an Active Distraction versus
Pleasant Unfamiliar Sounds and Music: The Influence of
Emotion and Cognitive Style
Eduardo A. Garza Villarreal1,2*, Elvira Brattico4, Lene Vase1,3, Leif Østergaard1,5, Peter Vuust1,2
1Center of Functionally Integrative Neuroscience, University of Aarhus, Aarhus, Denmark, 2The Royal Academy of Music, Aarhus and Aalborg, Denmark, 3Department of
Psychology, University of Aarhus, and Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark, 4Cognitive Brain Research Unit, Cognitive Science,
Institute of Behavioral Science, University of Helsinki & Centre of Excellence for Interdisciplinary Music Research, University of Jyva ¨skyla ¨, Jyva ¨skyla ¨, Finland, 5Department
of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
Listening to music has been found to reduce acute and chronic pain. The underlying mechanisms are poorly understood;
however, emotion and cognitive mechanisms have been suggested to influence the analgesic effect of music. In this study
we investigated the influence of familiarity, emotional and cognitive features, and cognitive style on music-induced
analgesia. Forty-eight healthy participants were divided into three groups (empathizers, systemizers and balanced) and
received acute pain induced by heat while listening to different sounds. Participants listened to unfamiliar Mozart music
rated with high valence and low arousal, unfamiliar environmental sounds with similar valence and arousal as the music, an
active distraction task (mental arithmetic) and a control, and rated the pain. Data showed that the active distraction led to
significantly less pain than did the music or sounds. Both unfamiliar music and sounds reduced pain significantly when
compared to the control condition; however, music was no more effective than sound to reduce pain. Furthermore, we
found correlations between pain and emotion ratings. Finally, systemizers reported less pain during the mental arithmetic
compared with the other two groups. These findings suggest that familiarity may be key in the influence of the cognitive
and emotional mechanisms of music-induced analgesia, and that cognitive styles may influence pain perception.
Citation: Garza Villarreal EA, Brattico E, Vase L, Østergaard L, Vuust P (2012) Superior Analgesic Effect of an Active Distraction versus Pleasant Unfamiliar Sounds
and Music: The Influence of Emotion and Cognitive Style. PLoS ONE 7(1): e29397. doi:10.1371/journal.pone.0029397
Editor: Andrew H. Kemp, University of Sydney, Australia
Received August 3, 2011; Accepted November 28, 2011; Published January 5, 2012
Copyright: ? 2012 Garza Villarreal et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study was financially supported by the Danish Basic Research Foundation, Ulla and Mogens Folmer Andersden Foundation, Funding for Research
in Neurology, The Academy of Finland (project number 133673), Augustinus Fonden and Grosserer L.F. Foghts Fond. The funders had no role in study design,
data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: email@example.com
The pain modulation system is influenced by several factors
such as cognition and emotion, which can alter the perception of
pain [1,2]. Importantly, several studies have indicated that
distraction from a nociceptive stimulus, or positive emotions
elicited by an external stimulus, can reduce pain [3,4,5,6,7,8]. It
was recently discovered that distraction modulates pain differently
from emotion [9,10].
Music is an example of an external and distracting stimulus with
cognitive and emotional features that can induce an analgesic
effect [11,12,13,14,15,16,17]. Several studies indicate that music
could play an important role as an adjunct treatment for medical
disorders for different reasons: it has been found to reduce pain as
well as the required dosage of analgesic medication necessary for
treatment, and it is beneficial to an individual’s overall well-being
[17,18,19,20,21,22,23,24]. However, there is still limited knowl-
edge about which features of the music are responsible for the
analgesic effect, and which neural mechanisms are involved,
possibly due to the choice of poor control conditions or the lack of
randomized controlled trials .
Recent studies have aimed to uncover the analgesic mechanisms
of music using an experimental acute pain design. Mitchell, et al.
2006  showed that music has a superior analgesic effect to an
active distraction such as mental arithmetic. However, the music
used in this study was self-chosen and familiar, and therefore,
individual preferences and familiarity could enhance the drive to
listen attentively to the music and thus act as a distractor from the
pain. This was corroborated by work from the same group
showing that familiar music increases pain tolerance more than
unfamiliar music . Roy et al. 2008  showed that pleasant
music reduces pain more than unpleasant music, and that the
emotional valence is negatively correlated with the amount of pain
reported. This is no surprise, since positive valence reduces pain
regardless of the sensory system [26,28,29,30]. However, the
unpleasant music used in the Roy et al. study did not increase the
pain as expected. Furthermore, even though this study used music
unknown to the participants, the music could be considered
mainstream and hence, possibly familiar to them. Therefore, the
effect of familiarity may have a higher role in the mentioned
Arousal is another emotional factor that has been related to pain
relief and in music, arousal interacts with valence to reduce pain
[29,30,31]. Therefore, valence and arousal are two interrelated
emotional mechanisms that are clearly linked to the analgesic
effect of music.
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Lastly, an important factor that plays a role in the study of the
analgesic effects of music is that the musical experience is highly
individual. The individual variability in cognitive style has not yet
been examined in earlier studies. Cognitive styles, such as being
empathic and having a tendency to focus on emotions, or being
systematic and having a tendency to focus on analytic structures,
can affect the perception of an external stimulus by focusing
attention to the different features and aspects of the stimulus
[32,33]. Because of this, individual cognitive style may contribute
significantly to the variability of the analgesic effect of music.
Understanding the features of the music that may reduce pain, and
the internal mechanisms in the participant could minimize
variability and increase the analgesic effect of music.
Evidence from most studies points to an analgesic effect of
music, whereas other studies, particularly clinical ones, show no
music-induced analgesic effect of music [34,35]. This suggests that
the analgesic effect of music is highly variable. The differences
observed between studies could be explained by the variability of
the musical features, the emotions involved, and the familiarity of
the music used in the various studies.
In this study, we wanted investigate whether music reduces pain
to a larger extent than an active distraction task when controlling
for known analgesic mechanisms such as familiarity, valence,
arousal, and individual cognitive style. To do so, we exposed
healthy participants with different cognitive styles (empathizers,
systemizers, balanced)  to experimental heat stimuli during
four different listening conditions: Mozart music, environmental
sounds, mental arithmetic and a control. The mental arithmetic
was an active distraction task, whereas the rest were passive
auditory stimuli. The Mozart music and environmental sounds
were unfamiliar and matched for valence and arousal to study the
attribution of these features to the analgesic effect. We hypoth-
esized that the active and passive stimuli would have an analgesic
effect when compared to the control, and that the environmental
sounds and Mozart music would have a superior analgesic effect to
mental arithmetic. We predicted that both environmental sounds
and Mozart music would lead to similar pain ratings in
participants if the main analgesic mechanisms were related to
cognition and emotion, and not to the music itself. Finally, we
hypothesized that valence, arousal, liking, and cognitive styles
would influence the analgesic effect of the auditory stimuli. In
particular, we expected that stimuli with positive valence, liked,
and with low arousal would be the most effective in reducing pain
perception. We further predicted that systemizer individuals would
show stronger analgesic effects during more cognitively demanding
and distracting tasks, whereas the pain perception in empathizers
would be more affected by highly liked positive auditory stimuli.
Materials and Methods
Forty-eight native Danish speakers (24 male, 24 female), aged
between 19 and 39 years (mean=24, SD=4), participated in the
experiment. All participants were healthy, right handed, reported
normal hearing and had minimal to no musical training. They had
not consumed any analgesic medication in the 24 hours prior to
the experiment. Participant recruitment was done via advertise-
ments and a research recruitment website. Upon inclusion in the
study, the participants filled out an online version of the Baron-
Cohen Empathizer-Systemizer Quotients in Danish [33,36].
Based on these results the participants were categorized and
divided into three groups: Empathizers (8m/8f), Systemizers (8m/
8f) and Balanced (8m/8f). Written informed consent was obtained
from all participants and the study was conducted according to the
Declaration of Helsinki. Participants received compensation for
taking part in the experiment. Ethical permission was obtained
from The Research Ethical Committee for Mid-Jutland Region,
Thermal stimuli and pain measures
The thermal stimuli were produced by a 363 cm contact
thermode (Pathway model ATS from Medoc Ltd. Advanced
Medical System, Israel) placed on the anterior surface of the
forearms. The pain limits and threshold were investigated for each
participant during calibration trials prior to the study in order to
control for individual differences in pain perception. In accor-
dance with Price et al. 1999 , we presented two trials with four
different temperatures: 42, 43, 45, and 47uC in a random order.
Each stimulus lasted ,10 s and was separated by approximately
15–20 s. The participants rated pain intensity and unpleasantness
on the Visual Analog Scale (VAS) (0–100 mm) at each
temperature. An individual goal temperature was determined,
which had to reflect pain ratings between 50–70 mm (moderate to
high) in the VAS.
In the experiment, the individual goal temperature was used as
the painful stimulus and was kept constant during the entire
experiment to avoid high variability of the VAS scores between
participants. To avoid habituation, the thermode was changed to a
slightly different skin location on the forearm after every two
experimental conditions. Both forearms were stimulated during
the experiment. Each painful stimulus consisted of a plateau of
16 s with a rise/fall time of 2 s. The baseline temperature was
35uC. The thermal stimulus was rated using the VAS for pain
intensity and unpleasantness. The scale ranged from ‘‘no pain’’
(left end of the scale) to ‘‘very intense’’ or ‘‘very unpleasant’’ (right
end) (0–100 mm) .
Prior to the experiment, we conducted a pilot study intended for
selecting musical pieces and environmental sounds most appro-
priate for this study. We recruited 18 healthy participants (9
males/9 females; mean age=27) who listened to a pool of 16
environmental sounds and 19 musical excerpts. The environmen-
tal sounds were recordings from nature (edited from the sound
effects library, Sound Ideas http://www.sound-ideas.com). There
were four excerpts of each type: Fire, Water, Rain and Wind. The
musical pieces were 19 different Mozart string compositions,
virtually unknown to the layman. The participants were required
to rate thestimuliaccording
10=pleasant), arousal (0=environmental, 10=stimulating), and
liking (0=not liked, 10=liked). The results showed that Rain and
Water for the environmental sounds and ‘‘String Quartet No. 1 in G
major, K. 80/73f (1770) – Adagio’’ and ‘‘Divertimento in E flat, K. 563 –
Adagio’’ for the music pieces, were rated as the most pleasant, liked
and relaxing. In this pilot study, the participants also reported that
pink noise was less distressing than white noise and therefore we
choose to include the prior as a control.
In the experiment, we used these selected musical pieces and
environmental sounds as well as the pink noise. Each auditory
stimulus lasted 300 s (5 min) and we performed peak normaliza-
tion on each of them. Peak normalization is an automated process
in which the software scans the entire signal to find the loudest
peak, and then adjusts each sample to a specific level. It is used to
ensure that the signal peaks at the loudest level allowed in a digital
system and does not cause clipping in the sound system. After the
experiment, the participants were asked if they had previously
listened to the musical piece, as familiarity with the music would
influence the analgesic effect.
to valence (0=unpleasant,
Superior Analgesia of Distraction versus Music
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The PASAT (Paced Auditory Serial Addition Test) was chosen
as the active distraction task. For details about the PASAT see
Gronwall, 1977 . The PASAT consisted of a woman’s voice in
Danish dictating numbers every three seconds. The task for the
participant consisted of adding together two of the numbers at a
time, the last dictated plus the new dictated number.
Each experimental condition lasted 300 s (5 min). The first
140 s consisted of passive listening (or active if it was the PASAT)
of the auditory stimulus, whereas the last 160 s consisted of the
auditory stimulus plus four thermal stimuli (Fig. 1). Listening to
music and other pleasant auditory stimuli elicits emotional
responses that might not be immediate, and such responses are
thought to be important for the analgesic effect of music and
reduction of anxiety . Therefore, the passive listening period
was included to ensure that the emotions and mood induced by
each auditory stimulus were present as much as possible. The
PASAT condition was considered the ‘‘active condition’’, and the
Noise, Rain, Water, Music 1 and Music 2 were considered the
After the experiment, the participants rated the auditory stimuli
on a 10-point Likert scales for valence (0=unpleasant, 10=pleas-
ant), liking (0=does not like, 10=likes), and arousal (0=relaxing,
The participants answered the Baron-Cohen Empathizer
Systemizer Quotients (two questionnaires) [33,36], which can
divide the population into three groups: Empathizers (more
empathic and social), Systemizers (attracted to patterns in objects
and events) and Balanced (in between). Empathizers are may be
attracted to the emotional content of the music, whereas the
Systemizers may be attracted to musicianship and performance
level . Although the Baron-Cohen quotient has not been used
in pain studies, it has been related to music listening styles .
Thus, the auditory stimuli may influence cognitive style and
potentially influencing cognitive and emotional mechanisms that
The categorization of the groups was done using the points from
each questionnaire that were then processed using the method
described in Wheelwright, et al. 2006 . In short, we used these
formulas: S=(SQ – 55.6)/150 and E=(EQ – 44.3)/80, then D=(S
– E)/2, where SQ (Systemizer quotient) and EQ (Empathizer
quotient) are the points from each of the questionnaires. The
resulting D was then used to find the category using the following
axioms: If D,2.21, then ‘Extreme Empathizer’ (EE); if D$2.21 but
,2.041, then ‘Empathizer’ (E); if D$2.041 but ,.040, then ‘Balanced’
(B); if D$.040 but ,.21, then ‘Systemizer’ (S); if D..21, then ‘Extreme
Systemizer’ (ES). For the purpose of this study, EE was merged with
E into the ‘Empathizer’ category, and ES was merged with S in
the same fashion. The mean points obtained in each questionnaire
by each group are shown in Table 1.
Figure 1. Paradigm. The complete paradigm lasted approx. 60 min. a. Here we show an example of the structure of each condition. The first 140 s
consisted of only the passive listening of the auditory stimulus (i.e. noise). Afterwards, the four thermal (pain) stimuli were delivered, with the auditory
stimulus still playing. ‘‘Pain’’ refers to when the thermal stimulus was ON, and ‘‘rest’’ refers to when it was OFF (no pain, baseline). The participants
rated the pain during ‘‘rest’’. b. Here we show the structure of a complete run. It consisted of the five random conditions (noise, rain, water, music1,
music2), lasting 5 min each, for a total of 30 min for one run. The whole paradigm consisted of two runs (60 min).
Table 1. Baron-Cohen E/S Quotient scores.
Systemizers39.75 6.3371.75 11.97
EQ=Empathizer Quotient, SQ=Systemizer Quotient, SD=Standard deviation.
Superior Analgesia of Distraction versus Music
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The participants were contacted prior to the experiment in order
to get the information regarding the thermal stimulation and they
were asked to answer the Baron-Cohen questionnaire. Once the
cognitive style was determined, each participant was assigned to a
group until the quota was fulfilled. The participants were asked to
come to the laboratory and were told that during the study they
weregoing toreceive painful stimuliwhile listening todifferenttypes
of auditory stimuli. When entering the laboratory they were told
that their task was to rate the pain. The experiment took place in a
sound proof white room without windows. Instructions for all
participants were identical and given by the same male experi-
menter, who was the only person present during the experiment.
The participants were trained to use the VAS and were familiarized
with the thermal stimuli by investigating pain limits and threshold.
They were also trained to perform the PASAT. They were seated
comfortably in a chair in front of a monitor and were given a mouse
to rate pain using a computerized VAS. To minimize confounds, a
panel wall stood between the experimenter and the participant to
avoid visual contact, and the participants were told that the
experimenter could not see their pain scores once the experiment
started. The auditory stimuli were presented using headphones
(Philips Hi Fi Stereo headphonesH SH P8900) at an individual
comfortable sound intensity level that remained constant through-
out the experiment. The auditory and thermal stimuli were
presented and controlled by a computer using PresentationH
software (Version 14.0, www.neurobs.com). The individual goal
temperature was kept constant during the study.
The paradigm included six conditions: two musical excerpts
(Music1, Music2), two environmental sounds (Rain, Water), an
active distraction task (PASAT), and a control (Noise). Each
condition lasted 300 seconds (5 minutes) for a total time of
30 minutes per run. Each experiment consisted of two runs per
participant with one minute of rest in between (Fig. 1). During
each condition, the auditory stimuli were presented for the entire
300 s. During the first 140 s, the participants listened passively (or
actively for the PASAT) to the auditory stimulus. During the
following 160 s, they also received four consecutive painful
thermal stimuli. After each painful stimulus, the participants had
20 seconds to rate it for intensity and unpleasantness. The
conditions were quasi-randomized, making sure the two environ-
mental sounds (Rain/Water) and the music pieces (Music1/
Music2) did not follow each other. After the experiment, the
participants rated the auditory stimuli for valence, liking and
arousal, and reported that the music pieces were unfamiliar to
The statistical analysis was performed using SPSS version 17.0
(SPSS Inc., Chicago IL). First, we compared the emotional
measures (valence and arousal) between groups in the pilot study
vs. in the experiment, with a one-way ANOVA to determine if the
overall ratings were similar. Then we compared each of the
conditions (Rain, Water, Music1, Music2) using a t-test as a post hoc
analysis. This was to confirm that the auditory stimuli used in the
experiment evoked the expected emotions. As the main analysis of
the experiment, we compared the pain ratings between conditions
using repeated-measures ANOVA. The dependent variables were
pain intensity (PI) and pain unpleasantness (PU). Furthermore, we
analyzed the emotional ratings between conditions again using
repeated-measures ANOVA. The dependent variables were valence,
arousal and liking.
For both repeated-measures ANOVAs (pain and emotion) we
studied the six-level within-subjects factor ‘‘condition’’: Noise,
PASAT, Rain, Water, Music1, Music2, and the between-subjects
factor ‘‘cognitive style’’. We performed single pre-hoc contrasts
using Noise as the contrasting condition, as well as post-hoc pairwise
comparisons to investigate differences between the all conditions.
The Bonferroni correction was used to control for multiple
comparisons. Type I errors were controlled for by using Mauchly’s
test and the Greenhouse–Geisser epsilon when appropriate.
Finally, we performed a Pearson correlation analysis to
determine the relationship between pain and emotion ratings.
For this, we computed an index of analgesia for each condition by
subtracting the pain ratings of a given condition from the ratings
during the control (Noise) condition. These subtracted pain scores
(PIs, PUs) were analyzed with valence, liking and arousal. Because
of previous knowledge regarding correlations between pain and
emotion, the analysis was one-tailed. The alpha level for all
statistical analyses was .05, unless stated otherwise. The effect sizes
of the main analyses were calculated using partial eta squared
(g2p). Effect sizes of the contrasts were calculated using the
Figure 2. Pain and emotion. a. Mean values of the VAS in each
condition. 0=‘‘no pain’’ and 100=‘‘worst pain’’. b. Mean values of the
ratings of valence, liking and arousal in each condition. Valence
(0=‘‘unpleasant’’, 10=‘‘very pleasant’’), liking (0=‘‘doesn’t like’’,
10=‘‘likes’’), arousal (0=‘‘relaxing’’, 10=‘‘stimulating’’).
Superior Analgesia of Distraction versus Music
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The one-way ANOVA (Valence: F (1, 248)=.865, p=.35;
Arousal: F (1, 248)=3.34, p=.07) and the individual t-tests showed
no significant differences between the pilot study ratings and those
of the experiment. This indicates that Rain, Water, Music1 and
Music2 were rated similarly in the pilot study and the experiment;
hence the stimuli evoked the intended emotions with respect to
valence, liking and arousal.
Analysis of pain
Figure 2 shows the descriptive statistics of pain and emotion
ratings for all the conditions. The repeated-measures ANOVA showed
a significant within-subjects effect of condition (Table 2) for PI and
PU, suggesting that the conditions were rated differently. The
contrasts showed that Noise was rated to be significantly more
painful than the rest of the conditions, which was expected as
Noise is the control condition. The effect sizes revealed that the
PASAT had the highest effect in both pain dimensions, and Rain
had the lowest. The post-hoc pairwise comparisons showed the
PASAT had significantly lower PI ratings than Rain, Water,
Music1 and Music2. On the other hand, in the PU the PASAT
was not significantly different from Music1, suggesting that Music1
reduced PU to the same extent as the PASAT. In PI, the passive
conditions (Rain, Water, Music1 and Music2) were not signifi-
cantly different from each other, suggesting that PI was similarly
rated across conditions. In PU, the passive conditions were also
not significantly different from each other, except Rain, which was
significantly more painful than Music1.
The between-subjects effect of cognitive style in PI and PU was
not significant, suggesting that empathizers, systemizers and
balanced rated PI and PU similarly. However, there was a
significant interaction between condition and cognitive type in PI,
due to the systemizers reporting less PI during the PASAT
condition than the empathizers and balanced participants (Fig. 3).
Analysis of emotion
The repeated-measures ANOVA showed a significant within-
subjects effect of condition (Table 3) for valence, liking and
arousal, indicating that the conditions were rated differently. The
contrasts showed that Noise was rated significantly different than
the rest of the conditions in valence (least pleasant), liking (least
liked) and arousal (more stimulating), except that Noise and
PASAT conditions were rated similarly for valence. The post hoc
pairwise comparisons showed that the PASAT was significantly
different than Rain, Water, Music1 and Music2 in valence (less
pleasant), liking (less liked) and arousal (more arousing). In liking
and arousal, the passive listening conditions did not differ
significantly, suggesting they were rated similarly. In valence, only
Rain was significantly less pleasant than Water and Music1. The
rest of the conditions in valence were not significantly different.
The between-subjects effect of cognitive style was not significant
for valence, liking and arousal; meaning Empathizers, Systemizers
and Balanced rated the emotions similarly.
There was a significant low negative correlation between PIs
and valence (p=.006, r=2.16), and a significant medium positive
Table 2. Results of the repeated-measures ANOVA of the pain ratings.
ConditionF (3.28, 147.36)=22.58, p=.000, g2p=.33F (3.35, 150.92)=12.56, p=.000, g2p=.22
Noise vs. PASATF (1, 45)=50.22, p=.000, r=.73 F (1, 45)=30.12, p=.000, r=.63
Noise vs. RainF (1, 45)=4.70, p=.036, r=.30 F (1, 45)=4.26, p=.045, r=.29
Noise vs. WaterF (1, 45)=15.32, p= .000, r=.50F (1, 45)=18.55, p=.000, r=.54
Noise vs. Music1F (1, 45)=13.01, p=.001, r=.47F (1, 45)=22.31, p=.000, r=.58
Noise vs. Music2F (1, 45)=6.49, p=.014, r=.36F (1, 45)=9.19, p=.004, r=.41
PASAT vs. Rainp=.000p=.002
PASAT vs. Waterp=.000p=.013
PASAT vs. Music1p=.000n.s.
PASAT vs. Music2p=.000p=.013
Rain vs. Watern.s.n.s.
Rain vs. Music1n.s.p=.035
Rain vs. Music2n.s. n.s.
Water vs. Music1n.s.n.s.
Water vs. Music2n.s.n.s.
Music1 vs. Music2n.s. p=.049
Interaction=Condition6Cognitive type F (10, 225)=2.04, p=.05n.s.
n.s.=Not significant, PI=Pain intensity, PU=Pain unpleasantness, r=effect size, g2p=effect size partial eta squared.
Superior Analgesia of Distraction versus Music
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correlation between PIs and arousal (p,.001, r=.26). Therefore,
the more pleasant and relaxing the auditory stimulus was, the less
pain intensity was perceived. There was near significant low
correlation with liking (p=.057, r=2.10). For PUs, there was a
significant positive correlation with arousal (p,.005, r=.18), but
not with valence (p=.08, r=2.09) or liking (p=.41, r=2.02).
Thus the more relaxing the auditory stimulus was, the less pain
unpleasantness was perceived.
In this study we found that the active distraction, represented by
mental arithmetic, reduced pain more than the passive distrac-
tions, which included music and sounds. Environmental sounds
and Mozart music had an analgesic effect, however they reduced
pain similarly, which is probably explained by their matched
valence, liking and arousal as rated by the participants. Pain
intensity was significantly correlated with valence and arousal,
whereas pain unpleasantness was only correlated with arousal.
Finally, participants with the cognitive style systemizer perceived
less pain intensity than empathizers and balanced during the
mental arithmetic condition.
Distraction vs. music
Contrary to our hypothesis, the active distraction by PASAT
reduced pain intensity more than the music and environmental
sounds. Also, PASAT reduced pain unpleasantness more than
Rain, Water, Music2, but not Music1. Thus, it is clear that the
active distraction was superior to the passive distractions in
reducing pain in general.
The analgesic effect of the PASAT can be considered to reflect
distraction as its mechanism [10,41]. Another analgesic mecha-
nism involved in the pain relieving effect of the PASAT may be
stress-induced analgesia (SIA), where exposure to a stressful
stimulus suppresses pain . Performing mental arithmetic while
receiving and rating pain may provide enough stress to elicit this
survival mechanism. Our results are in contrast with the findings
of Mitchel et al. 2006, which showed that music was superior to
PASAT in relieving pain. However, several differences in
experimental design may explain this discrepancy. Mitchell and
colleagues elicited pain using the cold pressor, a technique that is
thought to emulate chronic pain, whereas we used localized heat
eliciting acute pain . The different types of experimentally
elicited pain could be affected differently by stimuli such as music.
Moreover, although they measured both pain tolerance and
intensity, they only found a difference in pain tolerance and not in
pain intensity. In contrast, we did find a difference in pain intensity
and unpleasantness. Most importantly, in the study by Mitchell et
al. the music was self-chosen and familiar, whereas in our study the
music was experimenter-chosen and unfamiliar. Mitchel et al.
showed that familiar music provides a higher pain tolerance than
unfamiliar music . Therefore, familiarity with the music may
be crucial to direct the attention to the music, increasing the
distraction from the noxious stimulus.
Music vs. sounds
The environmental sounds and Mozart music both reduced
pain significantly compared to the noise. This provides further
evidence for the analgesic effect of music, and also for the analgesic
effect of auditory stimuli in general. The environmental sounds
and Mozart music were unfamiliar to the participants and were
characterized by a comparable range of valence (high), liking
(high) and arousal (low). Both environmental sounds and Mozart
music reduced the same amount of pain intensity (the sensory
perception of the noxious stimulus). Also, the sounds and music
had similar ratings of arousal. On the other hand, the condition
Rain was associated with the highest ratings of pain unpleasant-
ness (the emotional perception of the noxious stimulus), whereas
Music1 had the lowest rating when compared to noise (and
significantly differed from Rain). Rain was also the condition with
the lowest valence and liking, whereas Music1 had the highest.
Moreover, Rain was significantly different than Water and Music1
in valence. In sum, our results suggest that the analgesic effect of
music is probably not due to features of the music but more to
cognitive and emotional factors, as we showed that music had
similar analgesic effects to environmental sounds when valence,
liking and arousal ratings were similar.
The correlation analysis shows a negative relationship between
valence and pain intensity, and a positive relationship between
arousal and pain intensity. Although the size of the correlation
coefficients is small, it supports the results from Roy et al. 2008, in
which they showed that valence and arousal correlate with pain
intensity and unpleasantness. In relation to pain unpleasantness,
we only found correlation to arousal, but not to valence. All of our
auditory stimuli were unfamiliar and experimenter-chosen, which
can explain the low or lack of correlations. Familiarity is a long-
term recognition memory process that refers to a subjective state of
awareness according to prior experience . This memory
process is related to hedonistic judgments such as listening to
preferred music . Recent studies show low or lack of
Figure 3. Cognitive styles. Top. Mean pain intensity scores (VAS) for
each cognitive style and condition. The * indicates statistical
significance. Bottom. Mean pain unpleasantness scores (VAS) for each
cognitive style and condition.
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correlations of valence and arousal with unfamiliar music,
probably due to lack of emotional engagement [46,47]. Thus,
familiarity could be key in the induction of analgesic effects related
to emotional and reward mechanisms by means of memory and
prior exposure. Moreover, this effect may also be due to perceived
control, a known cognitive analgesic mechanism [2,48]. There-
fore, even though the sounds and the music in our study reduced
pain, as the participants were not emotionally entangled with the
auditory stimuli, the analgesic mechanisms might be less related to
emotion than previously thought when the music is not familiar.
Sytemizers perceived less pain during the mental arithmetic
than empathizers and balanced participants (Fig. 3). Systemizing is
the drive to analyze variables, derive the underlying rules that
govern the behavior of a system, and to control and construct
them [33,36,49]. Because of this, they may be attracted to patterns
and complex stimuli. Thus, systemizers may find the mental
arithmetic more entraining and distracting than the passive
distractions. This could explain the reduction in their pain
perception in the PASAT condition. In contrast, empathizers
and balanced cognitive styles were not related to increased
analgesic effects in any condition. Empathizing is the drive to
identify another person’s emotions and thoughts to respond to
these with an appropriate emotion, to predict behavior and to care
about the feelings of others. Balanced refers to the participants
with similar systemizing and empathizing scores. These two
cognitive styles were not related to responses to auditory stimuli
that may influence pain perception. There are several possible
explanations for this: 1) Cognitive styles may not influence
emotional and cognitive mechanisms of passive auditory percep-
tion, 2) the Baron-Cohen E-S Quotient may not reveal emotional
mechanisms and responses, 3) the main analgesic mechanisms of
auditory stimuli are not emotional but cognitive when the stimuli
are unfamiliar. Future studies should investigate which of these
explanations are most likely responsible for the effect. Overall, our
study is the first to suggest and show that cognitive styles,
particularly systemizing and empathizing quotients, may affect
pain perception. Further research in systemizers could study other
stimuli or music with complex features that may be more
distracting to them.
Implications and future directions
In summary, we found significant effects of a primary task on
pain perception. In particular, a task involving active distraction
was superior to unfamiliar passive tasks to reduce pain. The
Mozart music reduced pain as well, however it had the same effect
as environmental sounds with similar ratings of valence, arousal
and liking. This suggests that it is valence, arousal and liking that
seem to drive the analgesic effect of music rather than the music
itself. Familiarity with the music may influence the emotional
mechanisms to modulate the pain. When the music is unfamiliar,
the main analgesic mechanisms may be instead cognitive. The
results also show that the cognitive systemizing style influenced the
analgesic effect of the active distraction only. Nevertheless,
considering its significant analgesic effect compared to noise
(although smaller than the PASAT) in the clinical context, music
used as an analgesic adjuvant, would be preferable to mental
arithmetic as the PASAT could be highly arousing and stressful for
the patient. Furthermore, the PASAT task is highly dependent on
individual cognitive abilities and mental state and may not be
Table 3. Results of the repeated-measures ANOVA of the emotion ratings.
ConditionF (3.82, 171.85)=50.06, p=.000, g2p=.53F (3.73, 175.28)=37.70, p=.000, g2p=.45F (2.80, 125.75)=22.93, p=.001, g2p=.34
Noise vs. PASATn.s. F (1, 45)=13.35, p=.001, r=.48 F (1, 45)=28.72, p=.000, r=.62
Noise vs. RainF (1, 45)=46.71, p=.000, r=.71F (1, 45)=60.34, p=.000, r=.76F (1, 45)=8.30, p=.006, r=.39
Noise vs. WaterF (1, 45)=88.05, p=.000, r=.81 F (1, 45)=91.74, p=.000, r=.82 F (1, 45)=13.20, p=.001, r=.48
Noise vs. Music1F (1, 45)=100.73, p=.000, r=.83F (1, 45)=97.58, p=.000, r=.83F (1, 45)=3.58, p=.065, r=.27
Noise vs. Music2F (1, 45)=87.31, p=.000, r=.81F (1, 45)=85.31, p=.000, r=.81F (1, 45)=5.19, p=.027, r=.32
PASAT vs. Rainp=.000p=.005p=.000
PASAT vs. Waterp=.000p=.000p=.000
PASAT vs. Music1 p=.000p=.000p=.000
PASAT vs. Music2p=.000p=.001p=.000
Rain vs. Waterp=.013n.s.n.s.
Rain vs. Music1p=.001n.s.n.s.
Rain vs. Music2n.s.n.s.n.s.
Water vs. Music1n.s. n.s.n.s.
Water vs. Music2n.s.n.s.n.s.
Music1 vs. Music2n.s.n.s.n.s.
n.s.=Not significant, r=effect size, g2p=effect size partial eta squared.
Superior Analgesia of Distraction versus Music
PLoS ONE | www.plosone.org7 January 2012 | Volume 7 | Issue 1 | e29397
feasible in certain patient whereas listening to music is affordable
and pleasant to almost everybody. Future studies should use
neuroimaging methods, such as fMRI, to further understand the
neural mechanisms behind the analgesic effects of music and
environmental sound listening in acute and chronic pain.
We would also like to thank the people who helped make this possible:
Arne Møller for his help and support; Joshua Skewes and Daniel
Campbell-Meiklejohn for their invaluable help programming the para-
digm; Else-Marie Jegindø, Nanna Brix Finnerup, Troels Staehelin Jensen,
and rest of the Danish Pain Research Center for their insight, advices and
for allowing the use of the thermode. Finally, thanks to Pierre Rainville for
Conceived and designed the experiments: EAGV EB LV LØ PV.
Performed the experiments: EAGV. Analyzed the data: EAGV EB LV.
Contributed reagents/materials/analysis tools: EAGV EB LV LØ PV.
Wrote the paper: EAGV EB LV LØ PV.
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