Emotion and Pain in Rheumatoid Arthritis

1. Emotion and Pain in Rheumatoid Arthritis Considerations for treatment Marion Swetenham Clinical Psychologist

2. Affective and Sensory pain pathways (Melzack and Wall (1982), The Challenge of Pain (pg 161-164)

3. Distinction between Affect and Emotion • Affect is a biological, innate, instinctive response to a stimulus and is fleeting, very brief. • It becomes a feeling through awareness and knowledge and an emotion by the additional recall of previous experience from memory.

4. Affect, Feeling and Emotion • Affect is Biology • Feeling is Psychology • Emotion is Biography • Nathanson (1992). The Affect System – In Shame and Price: Affect, Sex and the Birth of the Self (pp 47-72). New York: W.W. Norton & Co.

5. Right and Left Brain Processes in Pain Emotion and Cognition • Left Hemisphere - Dominant for verbal, conscious and serial information processing • Right Hemisphere – Dominant for nonverbal, unconscious and emotional information processing Schore, A. (2012). Right brain affect regulation… In The Science of the Art of Psychotherapy (pp 71-117). New York: Norton & Co.

6. Survival function of the Affective dimension • The affective dimension of pain is like the right brain’s “red phone”, that compels the mind to engage in self-protective responses such as avoidance and escape in response to severe pain (Schutz, 2005 pg 15). • Schutz, (2005), Neuropsychology Review, 15 (1), 11-27

7. The reign of pain falls mainly in the right brain • Right brain is dominant for processing pain (Symonds et al, 2006) • Affect interacts with Sensory pain – • Pain enhances amygdala activity • Amygdala linked to both facilitatory and inhibitory pathways to modulate pain. • Symonds et al (2006). Journal of Neurophysiology, 95 (6), 3823-3830

8. Need to name it to tame it • Left brain makes sense of the emotional responses of the right brain • Naming dysregulated emotions in a therapeutic setting can have the effect of quietening them down (taming it) • CBT plays an important role here

9. Emotion Regulation in Rheumatoid Arthritis • Ability to regulate emotions results in: • Lower pain levels (Connelly et al 2007) • Faster recovery (Hamilton et al 2005) • Improved perceived health (van Middendorp et al 2005)

10. Emotional regulation cont. • Requires that the individual has the ability to identify and name emotions Problem: • High prevalence of Alexithymia in people with chronic pain (Lumley & Asselin, 1997) and Rheumatoid Arthritis (Kojima et al, 2014, Baeza-Velasco et al, 2012).

11. Alexithymia – definitionVanheuel et al (2011), Psychology and Psychotherapy, 84, 84-97 • Difficulties in: • identifying feelings and distinguishing feelings and bodily sensations of emotional arousal • Describing feelings • Constricted Imaginal process • Stimulus bound, externally oriented

12. Typical presentation • Talks in a factual way – devoid of feeling words • Tendency to list physical symptoms or • State historical facts (external focus) • Reduced or inability to reflect.

13. Pain and emotion – A Vicious cycle • Brain regions that become hyperactive in response to pain can lead to the deactivation of regions responsible for cognitive and decision making processes.

14. Pain –Emotion Vicious Cycle • If you can’t name what is going on, emotion remains dysregulated • Dysregulated emotional states leads to sympathetic hyperarousal associated with pain.

15. Treatment - Distraction • Distraction – shifting focus of attention to another sensory modality • Can help to reduce pain intensity • Problem – benefits short lived

16. Problems with Distraction • Distraction is a form of avoidance • Avoidance – maintains anxiety • The more we distract from pain, the more anxious we become about pain.

17. Pain Desensitisation • The way to treat anxiety – particularly phobias is not to distract or avoid, but through graded exposure. • So what if we focus on the pain instead of distracting from it?

18. Pain Desensitisation cont… • Pain Desensitisation is based on principles of habituation • Focus is on the sensory quality of pain has the paradoxical effect of reducing pain intensity (Villemure & Bushnell,2002) • Reduces health anxiety (Hadjistavropoulous et al. 2000)

19. Name it to tame it • The process of pain desensitisation is also to name the pain as: • ‘not telling you anything new’ • might be a result of physical overactivity • Is temporary • Breathing rate: 3 secs in, hold 3 secs, 4-5 secs out.

20. Consider trauma • Pain can hold multiple meanings for patients. • Affect regulation learned very early • In the absence of secure attachment – patients may have no ability to regulate their emotional state

21. Role of the therapist • If patients cannot regulate their emotional state: • Affect attunement on the part of the health practitioner can directly affect the patient’s psychobiology (Adler, 2007)

22. Finally:Whenever you see a patient who presents with pain • Empathy is important • Ask questions that you need to ask. • Put yourself in the shoes of the patient.

23. Reference • Adler, H. M. (2007). Toward a biopsychosocial understanding of the patient-physician relationship: An emerging dialogue. Society of General Internal Medicine, 22, 280-285. • Aleman, A. (2005). Feelings you can’t imagine: towards a cognitive neuroscience of alexithymia. Trends in Cognitive Sciences, 9(12), 553-555. • Baeza-Velasco, C., Carton, S., Almohsen, C., Blotman, F., & Gely-Nargeot, M. (2012). Alexithymia and emotional awareness in females with painful rheumatic conditions. Journal of Psychosomatic research, 73, 398-400. • Chapman, R., & Gavrin, J. (1999). Suffering: the contributions of persistent pain. The Lancet, 353, 2233-2237. • Connelly, M., Keefe, F. J., Affleck, G., Lumley, M. A., Anderson, T., & Waters, S. (2007). Effects of day-to-day affect regulation on the pain experience of patients with rheumatoid arthritis. Pain, 131, 162-170. • De Gucht, V. (2003). Alexithymia and somatisation:: A quantitative review of the literature. Journal of psychosomatic research, 54, 425-434. • Hadjistavropoulos, H. D., Hadjistravopoulos, T., & Quine, A. (2000). Health anxiety moderates the effects of distraction vs attention to pain. Behaviour Research and Therapy, 38, 425-438. • Haliburn, J. (2000). Psychotherapy of Anorexia Nervosa 2000. Australian & New Zealand Association of Psychotherapy Bulletin, 10(3), 4-8. • Haliburn, J. (2012). Traumatic Attachment as Adaptation - The Biopsychosocial Impact. In T. van Leeeuwen & M. Brouwer (Eds.), Psychology of Trauma (Vol. 3, pp. 1-33). New York: Nova Science Publishers, Inc. • Hamilton, N. A., Zautra, A. J., & Reich, J. W. (2005). Affect and Pain in Rheumatoid Arthritis: Do individual differences in affective regulation and affective intensity predictt emotional recovery from pain? Ann Behav Med, 29(30), 216-224. • Ji, G., Sun, H., Fu, Y., Li, Z., Pais-Vieira, M., Galhardo, V., & Neugebauer, V. (2010). Cognitive Impairment in Pain through Amygdala-Driven Prefrontal Cortical Deactivation. Journal of Neuroscience, 30(15), 5451-5464. • Keefe, F. J., Beaupre, P. M., Gil, K. M., Rumble, M. E., & Aspnes, A. K. (2002). Group therapy for patients with chronic pain. In D. C. Turk & R. J. Gatchel (Eds.), Psychological Approaches to Pain Management: A Practitioners Handbook (Second ed., pp. 234-255). New York: The Guilford Press.

24. Kojima, M., Kojima, T., Suzuki, S., Takahashi, N., Funahashi, K., Kato, D., . . . Ishiguro, N. (2014). Alexithymia, Depression, Inflammation, and Pain in Patients with Rheumatoid Arthritis. Arthritis Care & Research, 66(5), 679-686. • Lumley, M. A., & Asselin, L. A. (1997). Alexithymia in chronic pain patients. Comprehensive Psychiatry. • Lumley, M. A., & Stettner, L. (1996). How are alexithymia and physical illness linked? A review and critique of pathways. Journal of psychosomatic research. • Melzack, R., & Wall, P. (1982). Affect theory of pain. In The challenge of pain (pp. 161-164). London: Penguin Books. • Nathanson, D. L. (1992a). The Affect System. In Shame and Pride: Affect, Sex and the Birth of the Self (pp. 47-72). New York: W.W Norton & Company. • Nathanson, D. L. (1992b). What is Emotion. In Shame and Pride: Affect, Sex and the Birth of the Self (Paperback ed., pp. 35-72). New York: W. W. Norton & Company. • Neugebauer, V., Li, W., Bird, G. C., & Han, J. S. (1996). The role of anterior insular cortex in social emotions. The Neuroscientist, 9(12), 553-555. • Price, D. (1999). The dimensions of pain experience. In Psychological mechanisms of pain and analgesia, Progress in Pain Research and Management. Vol 15 (pp. 43-70). Seattle: IASP Press. • Schore, A. N. (2012a). Right Brain Affect Regulation: An Essential Mechanism of Development, Trauma, Dissociation, and Psychotherapy. In The Science of the Art of Psychotherapy (pp. 71-117). New York: Norton & Co. • Schore, A. N. (2012b). The right brain implicit self lies at the core of psychoanalysis. In The Science of the Art of Psychotherapy (pp. 118-151). Norton. • Schore, A. N. (2012c). Toward a New Paradigm of Psychotherapy. In The Science of the Art of Psychotherapy (pp. 1-24). New York: Norton. • Schutz, L. E. (2005). Broad-Perspective Perceptual Disorder of the Right Hemisphere. Neuropsychology Review, 15(1), 11-27. • Steinweg, D. L., & Dallas, A. P. (2011). Fibromyalgia: Unspeakable Suffering, A Prevalence Study of Alexithymia. Psychosomatics. • Symonds, L. L., Gordon, N. S., Bixby, J. C., & Mande, M. M. (2006). Right-lateralized pain processing in the human cortex: an FMRI study. Journal of neurophysiology, 95(6), 3823-3830. • van Middendorp, H., Geenen, R., Sorbi, M. J., van Doornen, L. J. P., & Bijlsma, J. W. J. (2005). Emotion regulation predicts change of perceived health in patients with rheumatoid arthritis. Ann Rheum Dis, 64, 1071-1074. • Vanheule, S., Verhaeghe, P., & Desmet, M. (2011). In search of a framework for the treatment of alexithymia. Psychology and Psychotherapy: Theory, Research and Practice, 84, 84-97. doi:10.1348/147608310X520139 • Villemure, C., & Bushnell, M. C. (2002). Cognitive modulation of pain: how do attention and emotion influence pain processing? Pain, 95(3), 195-199.