Overcoming Pain

Why people experience chronic pain, and the power they have to de-intensify it

I’m Feeling It

Pain as predictor of psychological distress.

Feelings and emotions. Feelings and emotions. We encounter them every day. Charities appeal to our emotions with sad-looking celebrities talking over slide shows of abused animals. The packaging of personal hygiene products evokes our primal identification of the essence of being male or female. Even a hotel’s design of its windows anticipates the possibility of a particularly low emotional day for its guests: Just now I tried to let a little fresh air in my hotel room as I pack to return back from a conference in San Francisco; but the window refuses to open more than about fifteen degrees. As happy or not the guest in room 2662 might be today—the proprietor’s anticipation of self-destructive behavior impacts us all, whether we are inclined to take in a more unobstructed view from that high-rise, or end it all from that same beautiful perch.

Over the past decade, researchers from all disciplines have given more thought to the connection between an individual’s emotions and the primary outcome of a particular intervention. Included in the outcomes data from studies ranging from breast reconstruction to total knee replacement, you will see the results of questionnaires designed to assess the emotional and psychosocial state of subjects. So, it is not surprising that differentiating somatic from emotional influences on the experience of chronic pain has been of interest to clinicians and researchers for many years. Although prior research has not unequivocally specified these pathways at the anatomical level, some evidence, both theoretical and empirical, suggest that emotional reactions influence the experience of disease and non-disease-related pains. Other studies suggest that treatments directed at negative emotional responses reduce suffering associated with pain.

An interesting study was conducted to explore the influence of emotional reactions to pain as a predictor of psychological distress in a sample of adults with Sickle Cell Disease (SCD), the results published earlier this year in the “International Journal of Psychiatry in Medicine.” While most other studies have sought to identify the somatic experience of pain as significant predictor of negative emotional states, healthcare utilization and quality of life, this was that rare attempt to evaluate the relationship between negative emotional reactions to pain and subsequent psychological outcomes in adult patients with a chronic illness associated with pain.

The researchers found that the negative emotional reaction to the somatic experience of pain, controlling for the magnitude of the painful experience, was predictive of psychological distress, including anxiety about health and other issues, elevated levels of distrust, and the increased belief that one is isolated by experiences of illness from the general population. Negative emotional reactions to pain were also predictive of the number of symptoms endorsed by patients who suffer from SCD, and the level and depth of negative emotional distress.

These results highlight the need to better resource patients with SCD to manage and control their responses to pain as a way of possibly reducing later psychological distress. For example, it is possible that patients who have easy access to health care providers with well-defined plans for responses when painful crises arise may respond differently than patients without such resources. Negative experiences associated with the quest for the relief of pain may be associated with later and more complicated negative psychological consequences. In other words, the nature, unpredictability, and intensity of pain in adult patients with SCD may produce a more intense and debilitating overall experience, and potentially more emotional scars, when patients view and then respond to their disease state in a negative fashion.

And there are researchers actively trying to tackle the aforementioned issues. An article from a few months back in the “Scandinavian Journal of Pain” reported the results of a pilot study involving the management of fear-related chronic pain. The hypothesis was to integrate an emotion regulation approach since emotions are potent during exposure to that which is causing fear, as distressing emotions may both interfere with exposure procedures and patient motivation to engage in exposure. Indeed, the findings support the idea that negative emotions play an important role in chronic pain and exposure treatment for distressed patients: A hybrid treatment combining an emotion regulation-focused Dialectical Behavior Therapy inspired treatment with standard exposure for patients with chronic low back pain resulted in considerable improvements. It is striking that patients achieved clinically relevant improvements, often to “normal” ranges, on key outcome variables. The results suggest that treatments focusing on emotion regulation are helpful.

While these findings are in line with the fear-avoidance model, they also suggest that actively dealing with other negative emotions, in a goal-pursuit context, might be helpful clinically.

Obviously, this approach needs to be evaluated in a variety of different clinical settings, but it does serve to remind us all of the complexities involved with the treatment of chronic pain—and the rewards, in the form of pain relief for the patient and professional satisfaction for the therapist, that may be derived from acknowledging these complexities.

Now, if I could just get this window to open up a little more.

Mark Borigini, M.D., is a board-certified rheumatologist who has devoted his career to treating illnesses that cause chronic pain and disability.

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