Emotion and Pain in Rheumatoid Arthritis

Considerations for treatment

Marion SwetenhamClinical 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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