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Emotion and Pain in Rheumatoid Arthritis PowerPoint Presentation
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Emotion and Pain in Rheumatoid Arthritis

Emotion and Pain in Rheumatoid Arthritis

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Emotion and Pain in Rheumatoid Arthritis

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  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.