Physiology & Behavior, Vol. 58, No. 6, pp.

1281-1286, 1995
Copyright © 1995 Elsevier Science Inc.
Pergamon Printed in the USA. All rights reserved
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0031-9384(95)02071-3

]Effects of a Cold-Water Stressor

on Psychomotor and Cognitive Functioning
in Humans
P R I Y A G. PATIL,* J E F F R E Y L. A P F E L B A U M * A N D J A M E S P. Z A C N Y * t I

*Department of Anesfl'~esia and Critical Care, MC 4028, University of Chicago, 5841 South Maryland Avenue, Chicago,
IL 60637, USA tDepartment of Psychiatry, University of Chicago Pritzker School of Medicine, Chicago, IL, USA

Received 21 December 1994

PATIL, P. G., L L. APFELBAUM AND J. P. ZACNY. Effects of a cold-water stressor on psychomotor and
cognitive functioning in humans. PHYSIOL BEHAV 58(6) 1281-1286, 1995.--The effects of an acute stressful and
painful stimulus~ cold water, on psychomotor and cognitive functioning, was assessed in 14 healthy volunteers.
Subjects immersed their forearm in ice-cold water (2-3°C) and luke-warm water (37°C) for 3 min, and during this
time period a psychomotor or cognitive test was performed. These immersions were done over the course of two
experimental ses,;ions, spaced at least 2 days apart, with six trials in each session. Within each session, cold and warm
water immersions alternated. Results indicated that flicker-from-fusion threshold from the critical flicker frequency
test was higher in the cold-water condition than in the luke-warm-water condition, indicative of increased alertness
from the cold stimulus. Short-term memory was attenuated, however, in the cold-water condition. Performance on
other tests including those that required speed and/or concentration were not affected by the manipulation. Subjects
rated the cold-water stimulus as painful and bothersome, and their blood pressure was significantly elevated by the
stimulus. We conclude that a painful stimulus may affect psychomotor and/or cognitive functioning, but the
relationship is somewhat complex and depends on the particular tests used.

Pain Behavior Memory Cognition Psychomotor Human Stress Stressor

Cold

A NUMBER of studies have examined the effects of stress on
human psychomotor and cognitive functioning. Among the vari-
ables studied have been influenza and colds (26), sleep depriva-
tion (5,8,35), chronic fatig'ue (18,25), low ambient room tempera-
ture (28,31), food restriction (24), microgravitation (i.e., absence
of gravity) (17), immersion hypothermia (12), hypoglycemia
(9,14,30), and hypoxemia (20). Most of these stressors have
impaired psychomotor or cognitive functioning [but see (26) for
an exception].
Surprisingly, very few studies have examined the effects of a
stressor that most people come into contact with a number of
times throughout their lives: pain. Pain is a stressor in that it
increases stress hormone release, i.e., ACTH and cortisol, and
impairs the immune system [el. (13,15)]. There have only been
two studies, to our knowledge, which have examined the effects
of pain on psychomotor performance. In the first study (16),
seven volunteers were injected with diazepam. Approximately 3
h later, when the effects of the drug were dissipating, subjects
were injected with either vitamin B or saline in the left buttock.
The vitamin B injection was designed to induce pain. Despite
subjects' anecdotal reports of pain even 2 h after the vitamin B
injection, no statistically significant differences were found in the
subjects' psychomotor performance after the vitamin B injection
in comparison to the saline injection. Measures used to assess
psychomotor performance included critical flicker fusion, and
divided attention, hand-eye coordination, and choice reaction
tests. One interpretational problem with the conclusions in this
study included the lack of formal assessments of pain in the study
(i.e., all assessments were anecdotally reported). Also, the effects
of pain on psychomotor performance, per se, were not measured
because the baseline performance was already depressed from the
diazepam. In the second study (7), subjects immersed one of their
hands in ice-cold water on some trials and in luke-warm water on
other trims while they performed either a visual discrimination

1 To whom requests for reprints should be addressed.

1281
1282
test or a short-term memory test. In the visual discrimination test,
subjects focused on a visual stimulus while also having to detect
another visual stimulus in their visual periphery. In the short-term
memory test, subjects had to memorize a list of 11 digits.
Performance on the visual discrimination test was impaired by
the cold water immersion, while short-term memory was unaf-
fected by the stressor.
The purpose of the present study was to further and more
comprehensively examine the effects of an acute stressor that
induces pain on functioning. Rather than isolating one or two
tasks to represent the class of psychomotor/cognitive function-
ing, we chose a variety of tasks that tapped into different
functions: ability to react quickly (auditory reaction time), ability
to work on a task that was based on both speed and accuracy
(Digit Symbol Substitution Test), ability to coordinate hand with
eyes (hand-eye coordination test), ability to think abstractly
(logical reasoning), ability to remember (short-term memory
test), and ability to measure the threshold of detection of a
flickering light (Critical Flicker Frequency Test, a measure of
alertness). The cold-pressor paradigm was used to induce tonic
pain in which the subject immerses their forearm or hand into
ice-cold water (6). During the cold-pressor test, subjects per-
formed one of the above psychomotor tests. In a control condi-
tion, subjects performed the same test while immersing their
forearm in luke-warm water. The cold pressor test can be done
over an extended period of time (several minutes) and, therefore,
was our choice for inducing pain. Other commonly used labora-
tory measures of inducing pain (e.g., thermal pain) would have
been unacceptable for the purposes of this study because of the
short duration that those painful stimuli could be applied to the
subject. We predicted that because cold-induced pain is a stres-
sor, and other stressors have been shown to disrupt psychomotor
and cognitive performance, the cold water would also disrupt
performance.
METHOD
Subjects
Fourteen healthy volunteers participated in this study. At a
screening interview conducted by a trained member of our re-
search staff, prospective subjects completed the SCL-90, a ques-
tionnaire designed to assess psychiatric symptomatology (11),
and a health questionnaire designed to determine their psychiatric
and medical status. Candidates with any significant psychiatric
problems [such as any history of drug- or alcohol-related prob-
lems or Axis I psychiatric disorders (3)] were excluded. In
addition, a physical examination and resting EKG were per-
TABLE 1
ORDER OF TEST PRESENTATIONS FOR TWO
SUBJECTS IN THE STUDY*
Subject A
Temp: C LW C LW C LW
Session 1 A R T ART COORD COORD DSST MEM
Session 2 L R LR CFF CFF MEM DSST
Subject B
Temp: LW C LW C LW C paired fashion. As a result, each of the other five tests were
Session 1 C F F CFF LRT LRT COORD MEM
Session 2 A R T ART DSST DSST MEM COORD
* C = ice-cold water condition; L W = l u k e w a r m water condi-
tion; A R T = auditory reaction time test; C F F = Critical Flicker
Frequency Test; C O O R D = h a n d - e y e coordination test; D S S T =
Digit Symbol Substitution Test; L R T = Logical Reasoning Test;
M E M = m e m o r y test.
PATIL, APFELBAUM AND ZACNY
formed on prospective candidates. Those with significant medical
problems (e.g., hypertension, epilepsy, diabetes) were excluded
from the study. For all female participants, a pregnancy test was
completed prior to the first session. If the second session oc-
curred more than 1 week following the first session, a pregnancy
test was conducted prior to that session as well.
Before participating, each volunteer signed a written consent
form that described the details of the study: in the consent form,
subjects were informed that the purpose of the study was to
measure psychomotor and cognitive function while their forearm
was exposed to ice cold water and luke-warm water. Ten men
and four women participated in the study. The mean age for men
was 27.7 + 4.8 years, and the mean age for women was 27 ___3.2
years. Payment for study participation was made during a debrief-
ing session, held after the study. The study was approved by the
local Institutional Review Board.
Experimental Procedures
Subjects performed six psychomotor and cognitive tests with
their nondominant forearm immersed in either ice-cold water or
luke-warm water. There were a total of 12 trials over the course
of two experimental sessions (six tests × two temperature condi-
tions). Water temperature alternated across the trials within each
six-trial session (warm-cold-warm-cold-warm-coldfor seven sub-
jects, and cold-warm-cold-warm-cold-warm for the other seven
subjects). Each forearm immersion trial was 3 min, and intertrial
interval was 20 min. Sessions were separated by a minimum of 2
days and a maximum of 13 days (11 subjects completed the study
within a week). Each session lasted 2.5-3.0 h.
Before the first session, subjects participated in a practice
session to determine if they could hold their forearm in ice-cold
water for 3 min, and to become acclimated to the various tests
that would be used in the study. Each of the tests (see below)
were practiced, in the absence of water immersion, twice, with
the exception of the memory test, which was performed only
once. Also, at the beginning of each session, subjects practiced
the tasks to be performed during that experimental session twice
in the absence of water immersion (with the exception of the
memory test which was practiced once). A trial consisted of
performing the task while the nondominant forearm was im-
mersed in ice-cold or luke-warm water. At 25 s intra-immersion,
the experimenter would ask the subject to rate the pain and
bothersomeness of the immersion (on a scale of 1 to 10; 1
indicating absence of pain or bothersomeness, and 10 indicating
extreme pain or bothersomeness). At 30 s, the subject would
begin the assigned 2-min psychomotor or cognitive test. At 160 s
intra-immersion the pain and bothersomeness ratings would be
assessed again, and blood pressure would be measured.
Except for the memory test, each of the tests was presented in
matching pairs (e.g., the subject would perform the hand-eye
coordination test while the nondominant arm was immersed in
luke-warm water and then 20 min later the subject would perform
the same test while the nondominant arm was in ice-cold water).
The order of test pair presentations were randomized across
subjects. To prevent unintended recall of previous memory tests
during a session, one memory test was presented during each of
the two experimental sessions instead of presenting the test in a
rotated between subjects to pair with the single memory test (see
Table 1 for two of the test presentation schedules that were used
during the study).
Pain Manipulation
The forearm immersion apparatus consisted of a standard ice
chest divided into two compartments by a wire screen. In the
STRESS AND PSYCHOMOTOR FUNCTIONING
cold-water condition, the tank was filled with water, and ice was
added to one side of the screen (i.e., cold pressor test). The water
was held between 2-3°C. In the luke-warm water condition (i.e.,
control condition), the tank was filled with water at a temperature
of 37°C. A cradle for the subject's forearm was positioned in one
side of the chest, which allowed the subject to rest the forearm
while immersing it in the cold or lukewarm water. The water in
the ice chest was constantly circulated by an aquarium pump.
When the subject removed his/her arm from the ice-cold or
luke-warm water, the experimenter would dry the arm with a
towel and would instruct the subject to relax or read for the next
20 min until the next experimental trial.
Dependent Measures
Simple auditory reaction test. This test measures the time it
takes to react to an auditory stimulus (21). Twenty tones were
delivered at random tim,," intervals (between 1-10 s) in a 2-min
time period. The mean reaction time (in seconds) was the depen-
dent measure.
Critical flicker frequency (CFF) test. The CFF test measures a
subject's ability to discriminate a flickering light from a slow
flicker rate to a fast fli,:ker rate (i.e., fusion-from-flicker), and
from a fast flicker rate to a slow one (i.e., flicker-from-fusion)
(29). The subject was in,;tructed to look though an eye-piece into
a chamber (Lafayette Scientific Instruments, Lafayette, IN) that
contains a light that is flickering on and off. The rate of the
flicker started out very ~;low (5 Hz) and steadily increased to a
very fast flicker rate (100 Hz). The subject was instructed to
press a button when he/she could no longer detect that the light
was flickering. The flicker rate in hertz was recorded by the
experimenter. Following two successive repetitions of the
fusion-from-flicker test, 1:heflicker-from-fusion test was adminis-
tered twice in succession using the same procedure, but this time
the subject was instructed to press a button when a flicker could
be detected in the light.
Digit symbol substitution test (DSST). The DSST is a simple
paper-and-pencil test in which the subject must substitute a
symbol for a corresponding number (34). This test is considered a
general measure of cognitive and psychomotor functioning. There
is a legend at the top of the sheet of paper in which the numbers
1 through 9 are matched with simple symbols. The rest of the
page is filled with numbers that are not yet matched with
symbols. The subject was instructed to draw as many symbols
matched with the appropriate numbers from the legend at the top
of the page as he/she could in 120 s. The total number of
correctly matched symbds was recorded.
Hand-Eye coordination. In this test the subject tracked a
randomly moving target (a circle) on the computer screen using a
computer mouse (21). The object of this test was to keep a small
cross, which is controlled by the mouse, inside the moving circle
at all times as the circle moves randomly around the screen. The
length of the test was 2 min. The dependent measures derived
from this test included ,t) seconds outside of circle (number of
seconds that the cross exceeded one centimeter from the center of
the circle), b) mean distance between the cross and the circle (in
pixels), and c) number of mistakes (number of times the cross
exceeded one centimeter from the center of the circle).
Logical reasoning. The logical reasoning test (4) measures
higher mental processes such as reasoning, logic, and verbal
ability. This 2-min computerized test employs five grammatical
transformations (e.g., true vs. false statements, use of the verb
precedes vs. the verbs follows) on statements about the relation-
ship between two letters A and B (e.g., A is preceded by B--true
or false). The subject's t,tsk was to respond "True" or "False,"
1283
depending on the veracity of the statement, by depressing the 1 or
0 keys, on the number pad, which corresponded to true and false,
respectively. The number of statements answered correctly was
the dependent measure.
Memory. This test measures short-term memory by presenting
a sequential list of 20 words on the computer. These 20 words
were presented in approximately 45 s. The subject was then given
90 s to write down as many words as he/she could remember.
Different word lists were used for all sessions including the
practice session. To ensure comparability of words across ses-
sions, the 20-word lists were equated on factors such as image-
evoking ability of the words, degree of meaningfulness, and their
frequency of usage (22). The words in the lists had ratings of
imagery and concreteness of greater than 5.0, and frequency of
usage greater than 20 per million (32). This test was always
performed during the fifth or sixth trial of a 'session, because of
the desire to avoid any proactive interference from the initial
memory test that was practiced by subjects at the beginning of
each of the two sessions.
Pain assessments. The subjects were asked to rate the pain
and its bothersomeness, verbally, on a scale of 1-10 during each
immersion of the forearm in ice-cold or luke-warm water (1 = not
painful/bothersome at all and 10 = extreme pain/bothersome-
ness). The questions "How painful is it?" and "How much does
it bother you?" were posed at 25 s and at 160 s into the
immersions.
Data Analysis
Repeated measures of analysis of variance (ANOVA) was
used to analyze fusion-from-flicker and flicker-from-fusion per-
formance using temperature (two levels) and replication (two
levels) as factors for each test. A student's paired t-test was used
to analyze each of the following measures: auditory reaction;
DSST; hand-eye coordination; logical reasoning; and memory. A
one-tailed t-test was used because we had hypothesized that
performance would be impaired in the cold-water condition.
Repeated measures ANOVA was performed with pain intensity,
bothersomeness ratings, and all physiological measures using
session (two levels), trial (three levels), time (two levels), and
temperature (two levels) as factors.
RESULTS
Mean pain intensity ratings in the cold water condition were
5.9 + 0.1 and were 1.0 + 0.01 in warm water ( p < .001). Mean
bothersomeness ratings in the cold-water condition were 5.9 + 0.2
and were 1.1 + 0.3 in the warm-water condition ( p < .001). In
the cold-water condition, there were no significant interactions
between the two ratings taken within a trial (i.e., trial × time),
indicating that pain ratings most likely remained constant during
the time in which psychomotor/cognitive functioning was being
assessed. There were also no interactions indicative of increased
(sensitization) or decreased (tolerance or habituation) pain inten-
sity or bothersomeness ratings as a function of session, or trial
order (1 vs. 2 vs. 3) within a session. The differences in
cold-water and warm-water ratings clearly demonstrate that our
temperature manipulation did evoke differences in self-reported
pain levels.
The temperature manipulation had a marked effect on systolic
blood pressure [mean of 144.6 ± 15.6 mmHg in the cold-water
condition vs. 121.9 + 13.8 mmHg in the warm-water condition
( p < .001)] and diastolic blood pressure [mean of 83.2 ± 11.6
mmHg in the cold-water condition vs. 62.1 ± 10.2 mmHg in the
warm-water condition ( p < .001)]. These results demonstrate that
1284 PATIL, APFELBAUM AND ZACNY

cold water was a stressor as measured by our physiological

variables. In the cold-water condition, there were no interactions
Flicker-from-Fusion Frequency
indicative of increased (sensitization) or decreased (tolerance or 42
habituation) blood pressure as a function of session, or trial order
(1 vs. 2 vs. 3) within a session.
Performance on two of the six psychomotor/cognitive tests
examined in this study were significantly affected by the temper- 40
ature manipulation: critical flicker-frequency and short-term Hz
memory. The flicker-from-fusion frequency threshold was signif-
icantly elevated in the cold-water condition, relative to the 38
warm-water condition [temperature: F(1, 13) = 6.6, p < 0.02].
Figure 1 (top frame) shows that subjects detected the flicker
(from fusion) sooner in the cold-water condition than in the
luke-warm-water condition. Neither the replication ( p = 0.33) 36--
nor the temperature >(replication interaction ( p = 0 . 3 0 ) were Lukewarm Cold
significant. The bottom frame of Fig. 1 shows the effects of Temperature of Water
temperature condition on immediate free recall. The cold-water
immersion resulted in significantly fewer words being recalled
than in the luke-warm-water immersion, t ( 1 3 ) = 2.0, p < 0.03.
Table 2 presents the means ( + SEM) of the other tests in both
Short-Term Memory
immediate free recall
water temperature conditions. It is apparent that there was no 16T
effect of the temperature manipulation on performance of these
tests.

DISCUSSION 14 ¸

Our study investigated psychomotor and cognitive functioning words

recalled
in the presence and absence of a painful stimulus, cold water. We
hypothesized that there would be disruptions in the functioning of 12
our healthy normal volunteers in the presence of the painful three
minute ice-cold water immersions. The cold-water immersion
did, indeed, substantially elevate pain intensity and bothersome-
ness. In addition, the pain was a stressor, in that blood pressure Lukewarm Cold
was elevated in response to the cold-water immersion. Although
performance on the short-term memory and CFF tests were
Temperature of Water
affected by the cold-water immersion, these were affected in FIG. 1. Effects of the lukewarm-water and cold-water immersions on
opposite ways: flicker-from-fusion threshold was elevated (i.e., flicker-from-fusion frequency (Hz) from the Critical Flicker Frequency
improved) and short-term memory was impaired during the cold- test (top frame) and number of words recalled on the short-term memory
test (bottom frame).
water immersion.
The CFF test purportedly measures alertness (23). In one
sense, it is not surprising that a cold-water stimulus would
flicker-from-fusion threshold was more sensitive than fusion-
increase alertness, and hence, increase the flicker-from-fusion
from-flicker threshold when measuring the effects of stimulants
threshold. However, why this increased alertness was not re-
and depressants in healthy volunteers (2). It should be pointed out
flected in a increased fusion-from-flicker threshold is difficult to
at this time that there was an order effect in our study: fusion-
explain. Other studies that have examined both thresholds typi-
from-flicker threshold was always measured before flicker-from-
cally collapse across the ascending and descending series, and
fusion threshold. To what extent this order effect may have
report a mean CFF threshold; therefore, whether or not this
played a role in the disparate results in the CFF test is not known.
dissociation is a common occurrence is not known. However,
Assuming, though, that the cold-water immersion did increase the
there is at least one study in the literature that demonstrated that
alertness of our subjects, as reflected by the elevated flicker-
from-fusion threshold, it is admittedly not clear why other psy-
TABLE 2 chomotor tests in the battery did not show enhancement of
performance. Finally, the elevated flicker-from-fusion threshold
MEAN (± SEM) PERFORMANCEON PSYCHOMOTORAND
COGNITIVETESTS DURING LUKEWARM-AND results obtained in the present study appear to stand in contrast to
COLD-WATER IMMERSIONS the findings reported by Clark et al. (7) in which visual discrimi-
Warm Water Cold Water nation (sensitivity) was poorer during a hand immersion into cold
water than into lukewarm water. In sum, these apparent inconsis-
Auditory reaction time (ms) 318 (19) 325 (15)
Fusion-from-flicker threshold (Hz)* 35.5 (0.8) 36.3 (1.0)
tencies within the study and across studies are difficult to explain.
DSST (No. of symbols drawn correctly) 91.4 (3.9) 88.6 (4.6) Before dismissing the results as anomalous though, it is important
Eye-hand coordination to point out that 11 of our 14 subjects showed this phenomenon
Seconds outside of circle 11.3 (1.5) 12.2 (1.7) of the increased flicker-from-fusion threshold.
Mean distance from circle center 14.7 (0.7) 15.9 (1.4)
Mistakes 36.1 (4.5) 34.9 (4.7)
In one respect, the CFF results are consistent with the
Logical reasoning test (No. of statements Yerkes-Dodson law (36), which posits an inverted U-shaped
correctly answered) 29.2 (2.0) 28.5 (2.7) function between stress and performance. Our cold pressor test,
which could be construed as moderately stressful (i.e., mean pain
* Means are collapsed across the two replications. intensity rating was 5.9 + 0.1 rather than close to 10), did
STRESS AND PSYCHOMOTOR FUNCTIONING
enhance performance on this alertness test. On the other hand,
there were no further ex~a'nples of enhanced performance on any
of the other tests. The reason for this is admittedly unclear.
Subjects performed worse on the short-term memory test
during the cold-water immersion than the luke-warm--water
immersion. This is consistent with our hypothesis that stress
would impair performanc.e, and with other infrahuman and hu-
man studies showing that memory processes during extended
exposure to cold ambient air are impaired (1,26,31,33). However,
it is peculiar why we did not detect decrements in performance
on other tests that required the process of cognition, such as the
logical reasoning test.
The cold pressor test is thought to induce pain of a tonic, as
opposed to a phasic, nature. Therefore, the results of this study
might apply to pain that is short term, but continuous in nature.
Whether these results apply to painful stimuli delivered outside
of a laboratory setting is another matter. Pain is a multidimen-
sional entity, comprising sensory, emotional, and evaluative com-
ponents (19). We induced pain in a laboratory setting in which
most likely the emotional component of pain was missing. Typi-
cally, pain in a clinical situation elicits anxiety (10), which may
not have been present in this laboratory study. In past studies
conducted with the cold pressor test in our laboratory in which
we have assessed mood, anxiety has not been induced by the cold
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