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