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4 Articles in this Series
Introduction
Individualizing Pain Treatment: Start with Gender?
Simplifying Pain Self-Management for Patients
The Interactions of Emotions and Chronic Pain
To Treat Pain Better, Underlying Mechanisms Are Key

The Interactions of Emotions and Chronic Pain

with Afton Hassett, PsyD, and Burel Goodin, PhD

Depression may make pain worse, as physicians who care for chronic pain patients well know. However, the full spectrum of emotions—both positive and negative—may also affect pain, said Afton Hassett, PsyD, an associate research scientist at the Chronic Pain and Fatigue Research Center, at the University of Michigan in Ann Arbor. She spoke at a session on affect regulation, at the 2018 American Pain Society (APS) Scientific Summit.1

“Pain and emotions are processed by many of the same areas of the brain,” Dr. Hassett said, and these areas are interconnected. In a lively review at the annual meeting, she discussed how emotions affect pain—and what may be done to create more positive emotions and thereby reduce or manage related chronic pain.

Emotional Effects

Both negative and positive affective states play a role in pain, Dr. Hassett said. For instance, she pointed to various studies1 which have shown that:

  • Sadness may worsen the pain experience and influence cortical activity.
  • Patients who are hostile, angry, and have an inability to forgive tend to experience more severe pain.
  • Certain pain medications may affect emotions. Acetaminophen, for example, reduced self-report and neural responses to social rejection.
  • Cursing has been shown to reduce the experience of pain temporarily.
  • Laughter may truly be good medicine. “Duchenne laughter [the hearty laugh] resulted in an increased pain threshold,” in one study, said Dr. Hassett.
  • Love may be good for pain. When someone is in love, the nucleus accumbens, amygdala, and dorsolateral PFC are activated.

Specific negative states such as sadness, depression, fear, anxiety, anger, guilt, disgust, hatred, and rejection have all been linked with higher pain intensity, lower pain tolerance, hyperalgesia, greater use of pain medication, increased fatigue, poor quality of life, and higher levels of psychiatric comorbidity, among other problems.1

Positive states, including happiness, love, calmness, enthusiasm, interest, empathy, passion, determination, inspiration, and gratitude, on the other hand, have been linked with lower pain rating and intensity scores, increased tolerance of pain, longer tolerance, decreased use of pain medication, greater walking times post-surgery, and reduced length of stay in colorectal cancer surgery, among other benefits. (Dr. Hassett cited dozens of studies in her presentation, and the slides are available through APS.)1

“There is really good prospective and experimental evidence suggesting that positive affective states now can bring forward all the outcomes we want,” she explained, including reduced use of pain medication in this time of opioid focus.

Positive emotions may also help patients build their personal resources, Dr. Hassett said, including physical, intellectual, social and psychological.

How to Emphasize the Positive with Patients

Patients living with chronic pain have often lost the joy in life, Dr. Hassett said. “They do the things they must do. But the joy gets lost in life, and some of our patients even forget how to seek joy.” Her research, and that of others cited in her presentation,1 have focused on interventions that may enhance resilience and other positive activities.

Researchers have demonstrated that individuals with chronic pain found positive activities effective in reducing pain. In one study, 96 patients with pain caused by multiple sclerosis, neuromuscular disease, spinal cord injury, or post-polio syndrome enrolled in an 8-week class where they received positive interventions, or one in which they wrote about their activities during the past week.

To increase positive emotions, Dr. Hassett suggested the following four approaches for patients with chronic pain; she noted that these recommendations may be explained easily to patients by physicians or other healthcare team members:

  • Start a gratitude diary. Suggest that patients write down three things every day for which they are grateful. Items can be simple, such as a phone call from a friend. As they write, suggest that they smile.
  • Take time to savor. Instruct patients to take a couple of minutes each day to savor something they enjoy (eg, morning coffee, flowers outside the window).
  • Carry out acts of kindness. One day a week, a patient may try to do five kinds things for family, friends, or strangers. Tasks may include holding a door open, letting the person behind them at the grocery store go ahead, etc.
  • Carry out acts of self-kindness. This approach is similar to that above, but aimed at the patient. For example, he or she may take a bubble bath, walk in the park, or indulge in an afternoon nap.

Research on Resilience

The group that received positive activity intervention had better improvement in pain intensity, control, interference, life satisfaction, and expression.2 PRISM is the name of Dr. Hassett’s randomized clinical trial: Promoting Resilience with Innovative Self-Management. Her team is examining 300 spine pain patients with comorbid fibromyalgia to compare online self-management programs coached by medical assistants. One group is receiving online cognitive behavioral therapy (CBT); a second group is participating in resilience-enhanced CBT; and a third group is receiving usual care.

The CBT includes pacing, sleep, goal setting, relaxation, and reframing. The resilience-enhanced CBT includes savoring, relaxation, acts of kindness, and other activities.

One part of the resilience training, a piggy bank experiment, fell flat, Dr. Hassett told the APS audience. Participants wrote down what they were grateful for, put the slip of paper in a piggy bank, and read it all back the following month. When analyzing the piggy bank exercise in a general population sample and in breast cancer surgery patients, researchers found benefits, including lower negative affect and less pain. But among the chronic pain patient sample, the piggy bank slips said things like: “My back pain is horrid, but I am trying to smile,” or “I am happy to have a home to be unhappy in.” Dr. Hassett’s conclusion? Patients with chronic pain may best benefit from some of the other proposed interventions, but the piggy bank experiment was ineffective.

Perspective

Despite the piggy bank experiment failure, Dr. Hassett’s work ‘‘underscores that many of the brain structures responsible for processing pain signals (limbic system) are the same structures that process emotions,” said Burel Goodin, PhD, a clinical psychologist at the University of Alabama in Birmingham. “Therefore, it makes sense that pain and depression often go hand in hand, meaning one begets the other. This is why depression can literally hurt, and it can also be very invalidating for patients with chronic pain if they are made to feel that their pain is somehow less serious because depression is an etiological contributor.”

However, as Dr. Goodin noted, ‘‘the good news is that the opposite is also true.” Efforts to create more positive emotions may help the experience of pain. For that reason, it is important not just to minimize the negative emotions in a pain patient, but also to accentuate the positive. “This task is at the core of building resilience, which buffers the negative impact of pain on quality of life,” Dr. Goodin said.

Dr. Hassett disclosed that she consults for AbbVie Inc. (Chicago, IL).

Sources

1. Hassett A. At the Intersection of Affect Regulation, Reward/Value Processes and Placebo. Presented at the American Pain Society Scientific Summit. March 4-6, 2018, in Anaheim, California.

2. Muller R, et al. Effects of a tailored positive psychology intervention on well-being and pain in individuals with chronic pain and a physical disability: a feasibility trial. Clin J Pain. 2016;32(1):32-44.

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