Emotion and Pain in Rheumatoid Arthritis Considerations for treatment Marion Swetenham Clinical Psychologist
Affective and Sensory pain pathways (Melzack and Wall (1982), The Challenge of Pain (pg 161-164)
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.
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.
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.
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
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
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
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)
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).
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
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.
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.
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.
Treatment - Distraction • Distraction – shifting focus of attention to another sensory modality • Can help to reduce pain intensity • Problem – benefits short lived
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.
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?
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)
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.
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
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)
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.
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