Anger expression and chronic pain

Anger and substance use in HIV-positive patients with chronic pain

Chronic pain increases the risk of substance use in people living with HIV (PLWH). Depression and anxiety have also been identified as risk factors for substance use among PLWH. Relatedly, other negative mood states, such as anger, may influence chronic pain among PLWH. The current cross-sectional study examined whether the distinct negative mood state of anger is associated with substance use among 187 PLWH who report chronic pain. Using negative binomial regression analyses, we found higher levels of anger were positively associated with alcohol use. Higher levels of anger were inversely associated with benzodiazepine use. No association was found between anger and marijuana use, and there were no significant interactions between anger and pain severity on substance use. Our findings suggest that anger is an independent risk factor for substance use among PLWH and chronic pain. Addressing anger may be useful when adapting behavioral therapies in the treatment of pain among PLWH.

The Link between Fibromyalgia Syndrome and Anger: A Systematic Review Revealing Research Gaps

Anger has been associated with increased pain perception, but its specific connection with Fibromyalgia Syndrome (FMS) has not yet been established in an integrated approach. Therefore, the present systematic review focuses on exploring this connection, and based on this connection, delimiting possible gaps in the research, altogether aimed at improving FMS clinical intervention and guiding future research lines. Anger is considered a basic negative emotion that can be divided into two dimensions: anger-in (the tendency to repress anger when it is experienced) and anger-out (the leaning to express anger through verbal or physical means). The current systematic review was performed based on the guidelines of the PRISMA and Cochrane Collaborations. The Prospective Register of Systematic Reviews (PROSPERO) international database was forehand used to register the review protocol. The quality of chosen articles was assessed and the main limitations and research gaps resulting from each scientific article were discussed. The search included PubMed, Scopus, and Web of Science databases. The literature search identified 13 studies eligible for the systematic review. Levels of anger-in have been shown to be higher in FMS patients compared to healthy participants, as well as patients suffering from other pain conditions (e.g., rheumatoid arthritis). FMS patients had also showed higher levels of state and trait anxiety, worry and angry rumination than other chronic pain patients. Anger seems to amplify pain especially in women regardless FMS condition but with a particularly greater health-related quality of life´s impact in FMS patients. In spite of the relevance of emotions in the treatment of chronic pain, including FMS, only two studies have proposed intervention programs focus on anger treatment. These two studies have observed a positive reduction in anger levels through mindfulness and a strength training program. In conclusion, anger might be a meaningful therapeutic target in the attenuation of pain sensitivity, and the improvement of the general treatment effects and health-related quality of life in FMS patients. More intervention programs directed to reduce anger and contribute to improve well-being in FMS patients are needed.

At the Intersection of Anger, Chronic Pain, and the Brain: A Mini-Review

Chronic pain remains one of the most persistent healthcare challenges in the world. To advance pain treatment, experts have recently introduced research-driven subtypes of chronic pain based on proposed underlying mechanisms. Nociplastic pain (e.g., nonspecific chronic low back or fibromyalgia) is one such subtype which may involve a greater etiologic role for brain plasticity, painful emotions induced by life stress and trauma, and unhealthy emotion regulation. In particular, correlational and behavioral data link anger and the ways anger is regulated with the presence and severity of nociplastic pain. Functional neuroimaging studies also suggest nociplastic pain and healthy anger regulation demonstrate inverse patterns of activity in the medial prefrontal cortex and amygdala; thus, improving anger regulation could normalize activity in these regions. In this Mini-Review, we summarize these findings and propose a unified, biobehavioral model called the Anger, Brain, and Nociplastic Pain (AB-NP) Model, which can be tested in future research and may advance pain care by informing new treatments that address anger, anger regulation, and brain plasticity for nociplastic pain.

Associations between anger and chronic primary pain: a systematic review and meta-analysis

OBJECTIVES

Anger is a negative emotion characterized by antagonism toward someone or something, is rooted in an appraisal or attribution of wrongdoing, and is accompanied by an action tendency to undo the wrongdoing. Anger is prevalent in individuals with chronic pain, especially those with chronic primary pain. The associations between anger and pain-related outcomes (e.g., pain intensity, disability) have been examined in previous studies. However, to our knowledge, no systematic review or meta-analysis has summarized the findings of anger-pain associations through a focus on chronic primary pain. Hence, we sought to summarize the findings on the associations of anger-related variables with pain and disability in individuals with chronic primary pain.

METHODS

All studies reporting at least one association between anger-related variables and the two pain-related outcomes in individuals with chronic primary pain were eligible. We searched electronic databases using keywords relevant to anger and chronic primary pain. Multiple reviewers independently screened for study eligibility, data extraction, and methodological quality assessment.

RESULTS

Thirty-eight studies were included in this systematic review, of which 20 provided data for meta-analyses (2,682 participants with chronic primary pain). Of the included studies, 68.4% had a medium methodological quality. Evidence showed mixed results in the qualitative synthesis. Most anger-related variables had significant positive pooled correlations with small to moderate effect sizes for pain and disability.

CONCLUSIONS

Through a comprehensive search, we identified several key anger-related variables associated with pain-related outcomes. In particular, associations with perceived injustice were substantial.

[Distress tolerance and experience of chronic pain]

INTRODUCTION

Chronic pain is a highly prevalent condition that is associated with distressing somatic and emotional experiences. Consequently, an individual's distress tolerance, the perceived capacity to tolerate negative psychological and physical states, may influence their pain experience. This effect could be explained in part by a reduction in the catastrophic interpretation of pain which is associated with increased pain intensity and interference in everyday activities.

AIMS

The first aim of this study was to explore the association between the components of the 5-factor model of distress tolerance and (1) pain intensity and (2) pain interference in everyday activities. The secondary aim was to assess the potential mediating effect of pain catastrophizing in the eventual association between components of distress tolerance and (1) pain intensity or (2) pain interference in everyday activities.

METHOD

This is a cross-sectional study of adult (18 years or older) university students and staff with chronic pain (3 months). They were invited to complete the online questionnaire through an email invitation. Pain intensity and interference in everyday functioning were assessed with the corresponding subscales of the Brief Pain Inventory. The following instruments were used to assess the components of the 5-factor model of distress tolerance: Ambiguity Tolerance Scale (tolerance to ambiguity), Intolerance to Uncertainty Scale (reversed score: tolerance to uncertainty), Discomfort Intolerance Scale (reversed score: discomfort tolerance), Distress Tolerance Scale (tolerance to negative emotions), Frustration Discomfort Scale (tolerance to frustration). Participants also completed the Pain Catastrophizing Scale.

RESULTS

Eighty participants were recruited (57 % women, mean age=33.09; standard deviation=12,87). Tolerance to negative emotions was the only component of distress tolerance that was associated with pain (ß=-0.04; 95% CI): -0.07--0.01; t (78)=-3.06, p<0.01) or pain interference in everyday functioning (ß=-0.07; 95% CI: -0.10--0.03; t (78)=-3.97, p<0.01), independently of the others. Combined with age, these factors explained 16.2 % of the variance in pain intensity and 19.4 % of the variance in pain interference. Pain catastrophizing partially mediated the association between tolerance to negative emotions and pain interference in everyday functioning, but it was not involved in the association between tolerance to negative emotions and pain intensity.

CONCLUSION

Tolerance to negative emotions appears to be the most relevant aspect of distress tolerance in the context of chronic pain and is a potential clinical target that is independent and complementary from pain catastrophizing.

Mental health and behaviour in children with dystonia: Anxiety, challenging behaviour and the relationship to pain and self-esteem

PURPOSE

To ascertain whether young people with dystonia are more likely than the general population to have mental health and/or behavioural difficulties, and to explore factors that may contribute to these difficulties.

METHOD

Using a quasi-experimental design, 50 young people with dystonia aged 7-17 and their carers were recruited from the Evelina London Children's Hospital. Young people completed the Beck Youth Inventories and the Strengths and Difficulties Questionnaire. Carers completed the Strengths and Difficulties Questionnaire-Parent version and the Paediatric Pain Profile. Important medical factors, such as age of onset, motor severity and manual function were obtained from medical records.

RESULTS

One sample z tests showed young people with dystonia self-reported significantly higher levels of anxiety (p < .001) and prosocial difficulties (p < .01), with 48% experiencing clinically significant anxiety levels. They experienced significantly lower levels of anger, disruptive behaviour and conduct problems (all p ≤ .01). Carers reported significantly higher rates of emotional problems, hyperactivity and peer problems, and significantly lower prosocial behaviours (all p ≤ .01). Pearson's correlation coefficients showed lower levels of self-esteem were related to higher levels of anxiety (p = .015). High levels of pain were related to parent-rated conduct problems (p = .004). Age of dystonia onset and motor severity did not correlate with any of the psychological or behavioural measures.

INTERPRETATION/CONCLUSIONS

Our study suggests high rates of anxiety and behaviours that challenge in children with dystonia. Screening in movement clinics would be helpful in early identification and signposting for support.

Self-Rated Health and Pain Problems in Mothers of Healthy Children or Children Requiring Outpatient Observation or Hospitalisation: A Pilot Cross-Sectional Study

A child's illness or disability is a considerable stressor for the mother and a risk factor for many psychological problems and somatic diseases. The purpose of the study was to (1) assess the prevalence of poor SRH and pain, (2) compare self-rated health and pain, (3) and identify the determinants of SRH and pain in mothers of healthy children and children requiring ambulatory observation or hospitalization. The study covered 234 mothers of both healthy and unhealthy children who required outpatient observation or treatment at an intensive care unit, neonatal intensive care unit, or oncology department. To analyse the variables obtained, the following tools were used: Self-Rated Health, Numerical Rating, Interpersonal Support Evaluation List, Peritraumatic Distress Inventory, Modified Hospital Anxiety and Depression Scale, and Impact of Effects Scale-Revised. The self-assessment of health in mothers of healthy children and those in need of outpatient observation or hospitalization at units with various specialities differed in a statistically significant way. The severity of the average and maximum pain among mothers of healthy children and those with a history of disease differed statistically significantly. Poor SRH co-occurred with severe maximum pain in all of the examined groups. Both in the control group and the group of mothers of children requiring outpatient observation, poor SRH co-occurred with a high level of anxiety. Only in the control group was a correlation found between the severity of the average and maximum pain and the severity of anxiety and depression symptoms.

Pain-induced aggression and changes in social behavior in mice

The effects of neuropathic, formalin, and acetic acid-induced visceral pain were investigated on the social and aggressive behaviors in the Swiss male mice. Neuropathic pain was induced by tibial nerve transection (TNT). Also, somatic and visceral pain was conducted by intraplantar injection of diluted formalin (1%, 20 μl) and intraperitoneal administration of acetic acid (0.6%, 200 μl), respectively. Fourteen and twenty one days after the TNT surgery, and also, 1 and 7 days following formalin and acetic acid administration, the three-chambered test was used to determine sociability and preference for social novelty and resident/intruder test was used for the evaluation of the aggressive behaviors. In the sociability phase of the three-chambered test, all the three models of pain did not change the animal's sociability. However, in the social novelty preference phase, the animals in pain showed deficits in social novelty preference by a significant increase in the time spent with the familiar mice compared to the control groups. Also, animals in pain significantly showed more aggressive behaviors like biting and clinching and have much less attack latency in comparison to the control groups. Pain-induced changes in the social novelty preference and aggressive behaviors continued in the neuropathic group until the end of the experiment. However, 7 days following the induction of both formalin and visceral pain, animals' social memory, and aggression almost returned to the standard value. These results suggest that long-lasting pain could lead to social memory impairment and increase aggressive behaviors in mice.

Emotional Awareness and Expression Therapy Achieves Greater Pain Reduction than Cognitive Behavioral Therapy in Older Adults with Chronic Musculoskeletal Pain: A Preliminary Randomized Comparison Trial

Objective

Emotional awareness and expression therapy (EAET) emphasizes the importance of the central nervous system and emotional processing in the etiology and treatment of chronic pain. Prior trials suggest EAET can substantially reduce pain; however, only one has compared EAET with an established alternative, demonstrating some small advantages over cognitive behavioral therapy (CBT) for fibromyalgia. The current trial compared EAET with CBT in older, predominately male, ethnically diverse veterans with chronic musculoskeletal pain.

Design

Randomized comparison trial.

Setting

Outpatient clinics at the West Los Angeles VA Medical Center.

Subjects

Fifty-three veterans (mean age = 73.5 years, 92.4% male) with chronic musculoskeletal pain.

Methods

Patients were randomized to EAET or CBT, each delivered as one 90-minute individual session and eight 90-minute group sessions. Pain severity (primary outcome), pain interference, anxiety, and other secondary outcomes were assessed at baseline, post-treatment, and three-month follow-up.

Results

EAET produced significantly lower pain severity than CBT at post-treatment and follow-up; differences were large (partial η2 = 0.129 and 0.157, respectively). At post-treatment, 41.7% of EAET patients had &gt;30% pain reduction, one-third had &gt;50%, and 12.5% had &gt;70%. Only one CBT patient achieved at least 30% pain reduction. Secondary outcomes demonstrated small to medium effect size advantages of EAET over CBT, although only post-treatment anxiety reached statistical significance.

Conclusions

This trial, although preliminary, supports prior research suggesting that EAET may be a treatment of choice for many patients with chronic musculoskeletal pain. Psychotherapy may achieve substantial pain reduction if pain neuroscience principles are emphasized and avoided emotions are processed.

Pressure Pain Tolerance Predicts the Success of Emotional Awareness and Expression Therapy in Patients With Fibromyalgia

OBJECTIVES

Quantitative sensory testing may help predict treatment responses in individuals with chronic pain. Our objective was to determine whether evoked pain sensitivity at baseline predicted preferential treatment responses to either emotional awareness and expression therapy (EAET) or cognitive behavioral therapy (CBT) in individuals with fibromyalgia (FM).

METHODS

This was a secondary analysis of a previous randomized clinical trial, in which individuals with FM were randomized to EAET, CBT, or Education as a control intervention. Only females who completed baseline and post-treatment assessments were analyzed (n=196). The primary outcome was change in overall clinical pain severity from pretreatment to posttreatment, and the primary predictor of interest was pressure pain tolerance at baseline.

RESULTS

Among patients with low pain tolerance at baseline (n=154), both EAET and CBT led to small but significant improvements in clinical pain severity (CBT mean=0.66, 95% confidence interval [0.24-1.07]; EAET mean=0.76 [0.34-1.17]). Conversely, in patients with normal pain tolerance (n=42), there was no significant improvement in clinical pain after CBT (0.13 [-0.88 to 1.14]), a small improvement after FM Education (0.81 [0.14-1.48]), but a much larger and statistically significant improvement after EAET (2.14 [1.23-3.04]).

DISCUSSION

Normal levels of pressure pain tolerance at baseline predicted greater improvement in clinical pain severity after EAET than CBT. Quantitative sensory testing may provide insights about individual responses to psychologically based therapies for individuals with chronic pain.

Relationship between pain intensity, disability, exercise time and computer usage time and depression in office workers with non-specific chronic low back pain

OBJECTIVE

The purpose of this study was to investigate the relationship between pain intensity, disability, exercise time, and computer use time and depression in office workers with nonspecific chronic low back pain.

STUDY DESIGN/SETTING

A cross-sectional correlational study.

SUBJECTS

Sixty-one office workers diagnosed with nonspecific chronic low back pain METHODS: The participants' body mass index was calculated using their height and weight. The amount of time the participants spent using a computer or exercising per week was analysed. The Beck Depression Inventory was used to determine the degree of depression in the participants. The Oswestry disability index and the numeric pain rating scale were used to assess the severity and pain intensity of the participants.

RESULTS

There was a significant correlation between the Beck Depression Inventory, the Oswestry disability index (r = 0.419, p < .05), and the computer use time (r = 0.369, p < .05) of the participants. There was a correlation between the Oswestry disability index and the numeric pain rating scale (r = 0.677, p < .01). There were significant correlations among the sub items of the Oswestry disability index with the Beck Depression Inventory, in the order of personal management activities (r = 0.539, p < .01), standing (r = 0.519, p < .01), social activities (r = 0.421, p < .05), travelling (r = 0.381, P < .05), and walking (r = 0.357, p < .05).

CONCLUSION

Our hypothesis as a results of this study is that the depression of office workers with non-specific chronic low back pain is correlated with the computer using time and the degree of disability. Especially among their various disabled items, personal management activities, standing, social activities, travelling, and walking is related to depression.

Pain-related psychological issues in hand therapy

STUDY DESIGN

Literature review.

INTRODUCTION

Pain is a subjective experience that results from the modulation of nociception conveyed to the brain via the nervous system. Perception of pain takes place when potential or actual noxious stimuli are appraised as threats of injury. This appraisal is influenced by one's cognitions and emotions based on her/his pain-related experiences, which are processed in the forebrain and limbic areas of the brain. Unarguably, patients' psychological factors such as cognitions (eg, pain catastrophizing), emotions (eg, depression), and pain-related behaviors (eg, avoidance) can influence perceived pain intensity, disability, and treatment outcomes. Therefore, hand therapists should address the patient pain experience using a biopsychosocial approach. However, in hand therapy, a biomedical perspective predominates in pain management by focusing solely on tissue healing.

PURPOSE OF THE STUDY

This review aims to raise awareness among hand therapists of the impact of pain-related psychological factors.

METHODS AND RESULTS

This literature review allowed to describe (1) how the neurophysiological mechanisms of pain can be influenced by various psychological factors, (2) several evidence-based interventions that can be integrated into hand therapy to address these psychological issues, and (3) some approaches of psychotherapy for patients with maladaptive pain experiences.

DISCUSSION AND CONCLUSION

Restoration of sensory and motor functions as well as alleviating pain is at the core of hand therapy. Numerous psychological factors including patients' beliefs, cognitions, and emotions alter their pain experience and may impact on their outcomes. Decoding the biopsychosocial components of the patients' pain is thus essential for hand therapists.

Anger Inhibition and Pain Modulation

BACKGROUND

The tendency to inhibit anger (anger-in) is associated with increased pain. This relationship may be explained by the negative affectivity hypothesis (anger-in increases negative affect that increases pain). Alternatively, it may be explained by the cognitive resource hypothesis (inhibiting anger limits attentional resources for pain modulation).

METHODS

A well-validated picture-viewing paradigm was used in 98 healthy, pain-free individuals who were low or high on anger-in to study the effects of anger-in on emotional modulation of pain and attentional modulation of pain. Painful electrocutaneous stimulations were delivered during and in between pictures to evoke pain and the nociceptive flexion reflex (NFR; a physiological correlate of spinal nociception). Subjective and physiological measures of valence (ratings, facial/corrugator electromyogram) and arousal (ratings, skin conductance) were used to assess reactivity to pictures and emotional inhibition in the high anger-in group.

RESULTS

The high anger-in group reported less unpleasantness, showed less facial displays of negative affect in response to unpleasant pictures, and reported greater arousal to the pleasant pictures. Despite this, both groups experienced similar emotional modulation of pain/NFR. By contrast, the high anger-in group did not show attentional modulation of pain.

CONCLUSIONS

These findings support the cognitive resource hypothesis and suggest that overuse of emotional inhibition in high anger-in individuals could contribute to cognitive resource deficits that in turn contribute to pain risk. Moreover, anger-in likely influenced pain processing predominantly via supraspinal (e.g., cortico-cortical) mechanisms because only pain, but not NFR, was associated with anger-in.

Role of coping with negative emotions in cognitive behavioral therapy for persistent somatoform pain disorder: Is it more important than pain catastrophizing?

AIM

Cognitive behavioral therapy (CBT) is known to be effective for patients with persistent somatoform pain disorder (PSPD). Improvement of negative emotions in interpersonal stressful situations has been reported to reduce PSPD-related clinical pain. However, these associations in CBT remain unclear. Therefore, we examined the relation between changes in negative emotions and clinical pain symptoms after CBT by using a multiple regression analysis that included pain catastrophizing.

METHODS

We analyzed negative emotional intensity scores in stressful situations of 38 patients with PSPD who had completed CBT treatment and all the daily worksheets. Negative emotional intensity scores were recorded in daily worksheets during 12 weekly CBT sessions. Scores for the Pain Catastrophizing Scale (PCS), Visual Analogue Scale (VAS) as clinical pain intensity, Beck Depression Inventory - Second Edition (BDI-II), and State-Trait Anxiety Inventory (STAI) were also obtained at pre- and post-treatment. A multiple regression analysis was conducted using changes in VAS scores after CBT as the dependent variable, and changes in negative emotional intensity, PCS, BDI-II, and STAI scores after CBT, age, and sex as independent variables.

RESULTS

Negative emotional intensity scores decreased after CBT. In a multiple regression analysis, the emotional changes resulting from CBT depicted a modest positive relation with changes in VAS scores (β = 0.37; P < 0.05); however, there was no relation between changes in PCS scores after CBT and changes in VAS scores after CBT (β = 0.03).

CONCLUSION

The results show that negative emotions play an important role in the treatment effects of CBT for PSPD.

The relationship between anger regulation, mood, pain, and pain-related disability in women treated for breast cancer

OBJECTIVE

Anger, depressive symptoms, and anxiety are known reactions to cancer and suggested to modulate pain experience. We examined the association between anger regulation, mood, and pain in 952 breast cancer patients followed for 3 years.

METHODS

Preoperatively, the patients completed questionnaires about depressive symptoms (BDI), state anxiety (STAI), anger regulation (STAXI-2), and pains in the surgical and other areas. Experimental pain sensitivity was tested. In the follow-up, BDI and STAI were assessed at 1 and at 6 months and at 1, 2, and 3 years after surgery. Pain in the surgical area was evaluated during the first 7 days and at 1 and 3 years after surgery. Pain-related disability was assessed at 3 years after surgery. Latent profile analyses were performed to identify mood profiles, and regression analyses to find independent predictors for mood and pain variables.

RESULTS

Anger inhibition and pain had associations with ongoing depressive symptoms and anxiety. Pain-related disability was associated with high anxiety at a hazard ratio (HR) of 2.24 (95% CI, 1.17-4.27), with older age (HR 1.07, 95% CI, 1.01-1.13), and with pain in the surgical area (HR 3.04, 95% CI, 2.41-3.85), but not with anger variables. Any relationship between anger regulation and pain intensity disappeared after controlling for age and mood.

CONCLUSIONS

Different forms of pain are important to recognize and treat to support breast cancer patients' psychological well-being. Anger inhibition could be a target for psychotherapeutic intervention, to help with ongoing mood symptoms. The relationship between anger regulation and pain is not straightforward.

Emotionserleben und somatische Beschwerden

Zusammenfassung. Theoretischer Hintergrund: Aktuelle Modelle der Wahrnehmung körperlicher Beschwerden gehen davon aus, dass negative emotionale Zustände (z. B. Angst und Traurigkeit) eine zentrale Rolle bei der Symptomwahrnehmung spielen. Eine kausale Wirkung von Ärger auf den körperlichen Symptombericht wurde hingegen noch nicht ausreichend nachgewiesen. Fragestellung: Führt eine experimentelle Induktion von Ärger und Traurigkeit zu einem verstärkten Bericht körperlicher Beschwerden? Methode: 90 Studienteilnehmende wurden zufällig drei experimentellen Bedingungen zugewiesen. Mit einer autobiografischen Methodik wurden Ärger (n = 30) und Traurigkeit (n = 30) induziert. Eine dritte Gruppe (n = 30) diente als neutrale Kontrollbedingung. Bei allen Teilnehmenden wurden vor und nach der Induktion die Emotionswahrnehmung sowie der körperliche Symptombericht erhoben. Ergebnisse: Nach der Induktion von Ärger und Traurigkeit war ein Anstieg der intendierten Emotionen Ärger in der Gruppe „Ärger“, t (29) = -5.43, p < .001, und Traurigkeit in der Gruppe „Traurigkeit“ festzustellen, t (29) = -4.81, p < .001. Lediglich nach der Induktion von Traurigkeit, t (29) = -4.04, p < .001, nicht jedoch nach der Induktion von Ärger, t (29) = -1.52, p = .14, war eine Verstärkung des körperlichen Symptomberichts zu beobachten. Schlussfolgerungen: Die Ergebnisse belegen unterschiedliche Effekte negativer Emotionen (am Beispiel Ärger und Traurigkeit) auf den körperlichen Symptombericht. Implikationen der Befunde für zentrale psychopathologische Phänomene werden diskutiert.

Does the ability to express different emotions predict different indices of physical health? A skill-based study of physical symptoms and heart rate variability

OBJECTIVES

The outward expression of emotion has been frequently associated with better health outcomes, whereas suppressing emotion is thought to contribute to worse physical health. However, work has typically focused on trait expressive tendencies and the possibility that individual differences in the ability to express specific emotions may also be associated with health has not been widely tested.

DESIGN

A cross-sectional study of community dwelling adults.

METHODS

One hundred and twenty-eight participants aged 18-88 years completed questionnaires assessing demographics and health status, before attending a testing session in which resting heart rate variability (HRV) was assessed. Participants then completed a performance-based test of expressive regulatory skill in which they were instructed to enhance and suppress their emotional expressions while they watched film clips validated to elicit amusement, sadness, and anger. Participants rated subjective emotional experience before and after each clip, and their degree of expressivity was scored using FACS-based Noldus FaceReader.

RESULTS

Missing data resulted in a final sample size of 117. Linear regressions controlling for age, sex, diagnoses, and trait emotion revealed that greater ability to enhance sad expressions was associated with higher HRV while the ability to enhance expressions of joy was associated with lower symptom interference. In parallel models, the ability to flexibly regulate (both enhance and suppress) expressions of joy and sadness was also associated with lower symptom interference.

CONCLUSIONS

Findings suggest that the ability to regulate expressions of both sadness and joy is associated with health indices even when controlling for trait affect and potential confounds. The present findings offer early evidence that individual differences in the ability to regulate the outward expression of emotion may be relevant to health and suggest that expressive regulatory skills offer a novel avenue for research and intervention. Statement of contribution What is already known on this subject The tendency to outwardly express felt emotion generally predicts better health, whereas expressive suppression typically predicts worse health outcomes. Most work has been based on trait assessments; however, the ability to regulate the expression of felt emotion can be objectively assessed using performance-based tests. Prior work in mental health suggests that the ability to flexibly up- and downregulate the expression of emotion predicts better outcomes. What does this study add The first evidence that the ability to flexibly regulate expressions predicts indices of health. Skill in both expressing and suppressing facial expressions predicts better reported health. Skills with different emotions differentially predict symptom interference and cardiac vagal tone.

Anger Expression, Momentary Anger, and Symptom Severity in Patients with Chronic Disease

BACKGROUND

Anger expression styles are associated with physical health, and may affect health by modulating anger experience in daily life. Research examining this process in the daily lives of clinically relevant populations, such as patients with chronic disease, is needed.

METHOD

Community adults with asthma (N = 97) or rheumatoid arthritis (RA; N = 31) completed measures of trait-level anger expression styles (anger-in and anger-out), followed by ecological momentary assessments of anger and physical health five times daily for 7 days.

RESULTS

High anger-in predicted greater momentary anger, physical limitations, and greater asthma symptoms. High anger-out predicted reduced RA symptoms. Momentary anger was robustly associated with more severe symptoms in daily life. Three-way interactions showed that anger-in moderated these momentary anger-symptom associations more consistently in men.

CONCLUSIONS

Anger expression styles, particularly anger-in, may affect the day-to-day adjustment of patients with chronic disease in part by altering the dimensions of everyday anger experience, in ways that appear to differ by gender.

Assessing Anger Expression: Construct Validity of Three Emotion Expression-Related Measures

Self-report measures of emotional expression are common, but their validity to predict objective emotional expression, particularly of anger, is unclear. We tested the validity of the Anger Expression Inventory (AEI; Spielberger et al., 1985 ), Emotional Approach Coping Scale (EAC; Stanton, Kirk, Cameron, & Danoff-Burg, 2000 ), and Toronto Alexithymia Scale-20 (TAS-20; Bagby, Taylor, & Parker, 1994 ) to predict objective anger expression in 95 adults with chronic back pain. Participants attempted to solve a difficult computer maze by following the directions of a confederate who treated them rudely and unjustly. Participants then expressed their feelings for 4 min. Blinded raters coded the videos for anger expression, and a software program analyzed expression transcripts for anger-related words. Analyses related each questionnaire to anger expression. The AEI Anger-Out scale predicted greater anger expression, as expected, but AEI Anger-In did not. The EAC Emotional Processing scale predicted less anger expression, but the EAC Emotional Expression scale was unrelated to anger expression. Finally, the TAS-20 predicted greater anger expression. Findings support the validity of the AEI Anger-Out scale but raise questions about the other measures. The assessment of emotional expression by self-report is complex and perhaps confounded by general emotional experience, the specificity or generality of the emotion(s) assessed, and self-awareness limitations. Performance-based or clinician-rated measures of emotion expression are needed.

Contributions of physical function and satisfaction with social roles to emotional distress in chronic pain: a Collaborative Health Outcomes Information Registry (CHOIR) study

Individuals with chronic pain show greater vulnerability to depression or anger than those without chronic pain, and also show greater interpersonal difficulties and physical disability. The present study examined data from 675 individuals with chronic pain during their initial visits to a tertiary care pain clinic using assessments from Stanford University's Collaborative Health Outcomes Information Registry (CHOIR). Using a path modeling analysis, the mediating roles of Patient-Reported Outcomes Measurement Information Systems (PROMIS) Physical Function and PROMIS Satisfaction with Social Roles and Activities were tested between pain intensity and PROMIS Depression and Anger. Pain intensity significantly predicted both depression and anger, and both physical function and satisfaction with social roles mediated these relationships when modeled in separate 1-mediator models. Notably, however, when modeled together, ratings of satisfaction with social roles mediated the relationship between physical function and both anger and depression. Our results suggest that the process by which chronic pain disrupts emotional well-being involves both physical function and disrupted social functioning. However, the more salient factor in determining pain-related emotional distress seems to be disruption of social relationships, than global physical impairment. These results highlight the particular importance of social factors to pain-related distress, and highlight social functioning as an important target for clinical intervention in chronic pain.

Personality Traits of Suicidality Are Associated with Premenstrual Syndrome and Premenstrual Dysphoric Disorder in a Suicidal Women Sample

Objective

Both Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) might increase the risk of suicidal behavior. The aim of this study was to assess the relationship between personality dimensions specifically involved in suicidal vulnerability and PMS/PMDD.

Method

We collected data from 232 women consecutively hospitalized after a suicide attempt. We examined the relationship between impulsivity, aggressiveness/hostility, hopelessness, trait anger, affect intensity, emotional lability, and PMS/PMDD. Notably, we created an algorithm from the shortened Premenstrual Assessment form in order to assess PMDD status.

Results

The proportions of PMS and PMDD among female suicide attempters were 50% and 23% respectively. Women with PMS or PMDD were more likely to endorse most of these personality traits to than those without even after controlling for potential confounders. We found an impulsive-aggressive pattern of personality in women with PMS or PMDD, independently from the time of the menstrual cycle. Interestingly, trait anger remained associated with both PMS and PMDD independently of every other personality traits. The higher the anger level, the higher the risk was to suffer from both PMS and PMDD.

Conclusions

This study demonstrates a strong, independent association between PMS/PMDD and trait anger among a representative sample of female suicide attempters. It is of major interest for clinicians in view of addressing a substantial public health problem among women of reproductive age.

Negative affectivity, emotion regulation, and coping in migraine and probable migraine: a New Zealand case-control study

BACKGROUND

Migraine is a prevalent and disabling health condition. While there have been some suggestions that personality may be linked to migraine incidence, dose-response links to disability or impact are yet to be conducted and multivariate analyses are uncommon.

PURPOSE

The purposes of this study are to evaluate the personality characteristics differentiating migraine and probable migraine sufferers from matched controls in multivariate models and assess the possibility of a dose-response relationship.

METHODS

Fifty migraine sufferers and 50 age-, sex-, and ethnicity-matched controls in New Zealand completed personality measures including negative affectivity, coping, and monitoring-blunting.

RESULTS

Logistic regressions indicated that migraine status was concurrently predicted by Type D negative affectivity, more frequent venting and planning coping, and lower monitoring. There was little evidence to suggest a consistent dose-response type effect of personality on migraine; lower impact and disability were associated with greater openness to experiences, acceptance, and behavioural disengagement.

CONCLUSIONS

A personality profile characterised by moderate levels of negative emotion and irritability together with failures in inhibitory self-regulation may be associated with an increased risk of strict and probable migraine.

The role of anger in psychosocial subgrouping for patients with low back pain

BACKGROUND

Low back pain (LBP) is a common and costly condition that often becomes chronic if not properly addressed. Recent research has shown that psychosocial symptoms can complicate LBP, necessitating more comprehensive screening measures.

AIM

The present study investigated the role of psychosocial factors, including anger regulation, in pain and disability using a screening measure designed for LBP treated with physical therapy.

METHODS

One hundred three LBP patients initiating physical therapy completed an established screening measure to assess risk for developing chronic pain, and psychosocial measures assessing anger, depression, anxiety, fear-avoidance, and pain-catastrophizing before and after 4 weeks of treatment. Dependent variables were pain intensity, physical impairment, and patient-reported disability. Risk subgrouping based on anger and other psychosocial measures was examined using established screening methods and through using an empirical statistical approach.

RESULTS

Analyses revealed that risk subgroups differed according to corresponding levels of negative affect, as opposed to anger alone. General psychosocial distress also predicted disability posttreatment, but, interestingly, did not have a strong relationship to pain. Subsequent hierarchical agglomerative clustering procedures divided patients into overall high-distress and low-distress groups, with follow-up analyses revealing that the high-distress group had higher baseline measures of pain, disability, and impairment.

CONCLUSIONS

Findings suggest that anger may be part of a generalized negative affect rather than a unique predictor when assessing risk for pain and disability in LBP treatment. Continued research in the area of screening for psychosocial prognostic indicators in LBP may ultimately guide treatment protocols in physical therapy for more comprehensive patient care.

Impact of anger on the health-related quality of life of multiple sclerosis patients

Background:

There is evidence of the presence of a disturbed pattern of anger in multiple sclerosis (MS). Emotion changes, including anger, are thought to influence health-related quality of life (HRQoL). However, although deleterious consequences of anger on physical health have been well reported, there are no studies that have analysed the effects of anger on the HRQoL in patients with MS. Our purpose was to assess the extent to which anger impacts on the HRQoL of a cohort of MS patients.

Methods:

One hundred and fifty-seven consecutive MS patients were enrolled in the study. Participants were administered affective trait measures (Beck Depression Inventory, Beck Anxiety Inventory) and anger measures (the Spanish adapted version of the State-Trait Anger Expression Inventory-2). HRQoL was quantified using the Functional Assessment of MS.

Results:

Linear regression analyses revealed that even after controlling for socio-demographic and clinical variables, higher levels of anger expression-in (tendency to handle anger by keeping it inside) independently predicted worse overall HRQoL of MS patients (β = −0.15, p = 0.04). We further found that this relationship was moderated by gender, showing that anger expression-in is a more influential predictor of the HRQoL in women with MS.

Conclusion:

The present study provides evidence that anger negatively affects the HRQoL of MS patients. Our results may have implications for those involved in treating emotional complications of MS and especially regarding psychotherapeutic interventions to improve HRQoL of MS patients.

Pilot study of a compassion meditation intervention in chronic pain

BACKGROUND

The emergence of anger as an important predictor of chronic pain outcomes suggests that treatments that target anger may be particularly useful within the context of chronic pain. Eastern traditions prescribe compassion cultivation to treat persistent anger. Compassion cultivation has been shown to influence emotional processing and reduce negativity bias in the contexts of emotional and physical discomfort, thus suggesting it may be beneficial as a dual treatment for pain and anger. Our objective was to conduct a pilot study of a 9-week group compassion cultivation intervention in chronic pain to examine its effect on pain severity, anger, pain acceptance and pain-related interference. We also aimed to describe observer ratings provided by patients' significant others and secondary effects of the intervention.

METHODS

Pilot clinical trial with repeated measures design that included a within-subjects wait-list control period. Twelve chronic pain patients completed the intervention (F= 10). Data were collected from patients at enrollment, treatment baseline and post-treatment; participant significant others contributed data at the enrollment and post-treatment time points.

RESULTS

In this predominantly female sample, patients had significantly reduced pain severity and anger and increased pain acceptance at post-treatment compared to treatment baseline. Significant other qualitative data corroborated patient reports for reductions in pain severity and anger.

CONCLUSIONS

Compassion meditation may be a useful adjunctive treatment for reducing pain severity and anger, and for increasing chronic pain acceptance. Patient reported reductions in anger were corroborated by their significant others. The significant other corroborations offer a novel contribution to the literature and highlight the observable emotional and behavioral changes in the patient participants that occurred following the compassion intervention. Future studies may further examine how anger reductions impact relationships with self and others within the context of chronic pain.

Anger arousal and behavioral anger regulation in everyday life among patients with chronic low back pain: Relationships to patient pain and function

OBJECTIVE

The objective of this study was to determine the degree to which patient anger arousal and behavioral anger regulation (expression, inhibition) occurring in the course of daily life was related to patient pain and function as rated by patients and their spouses.

METHOD

Married couples (N = 105) (one spouse with chronic low back pain) completed electronic daily diaries, with assessments 5 times/day for 14 days. Patients completed items on their own state anger, behavioral anger expression and inhibition, and pain-related factors. Spouses completed items on their observations of patient pain-related factors. Hierarchical linear modeling was used to test concurrent and lagged relationships.

RESULTS

Patient-reported increases in state anger were related to their reports of concurrent increases in pain and pain interference and to spouse reports of patient pain and pain behavior. Patient-reported increases in behavioral anger expression were related to lagged increases in pain intensity and interference and decreases in function. Most of these relationships remained significant with state anger controlled. Patient-reported increases in behavioral anger inhibition were related to concurrent increases in pain interference and decreases in function, which also remained significant with state anger controlled. Patient-reported increases in state anger were related to lagged increases in spouse reports of patient pain intensity and pain behaviors.

CONCLUSIONS

Results indicate that in patients with chronic pain, anger arousal and behavioral anger expression and inhibition in everyday life are related to elevated pain intensity and decreased function as reported by patients. Spouse ratings show some degree of concordance with patient reports.

Quantitative evaluation of low back and labor pain. Memory of pain experienced during labor and the intensity of low back pain in older women with discopathy

<b>Background</b><br /> The aim of this study was to determine the intensity of previously experienced labor pains in the context of self-evaluated intensity of discopathy-related low back pain in female patients.<br /> <br /> <b>Participants and procedure</b><br /> The retrospective study included 57 women who received neurosurgical consultation under ambulatory conditions. The intensity of low back pain experienced by every patient was scored using the 11-grade Numeric Rating Scale (NRS-11; ranging from 0 to 10 points). Simultaneously, an obstetrical history was collected from every patient (year of delivery, intensity of labor pain assessed with NRS-11).<br /> <br /> <b>Results</b><br /> Overall, 57 women, aged between 27 and 88 years (mean 52.8 ±15.6 years), were examined. The age at delivery ranged between 17 and 35 years (mean 25.6 ±5.6 years). The patient-reported intensity of pain in the lumbosacral spine, assessed with NRS-11, ranged between 5 and 10 points (mean 7.9 ±1.7 points), while the intensity of labor pain ranged between 3 and 10 points (mean 8.6 ±1.9 points). Labor pain was perceived as more significantly intense than low back pain localized in the lumbosacral spine. In four cases (7%), the intensity of low back pain was re-scored upon asking about the intensity of previous labor pain.<br /> <br /> <b>Conclusions</b><br /> Labor pain experienced during full-term vaginal delivery is characterized by significantly higher intensity as compared to low back pain. The memory of pain experienced during previous labors can attenuate the intensity of discopathy-related low back pain.

Further validation of a measure of injury-related injustice perceptions to identify risk for occupational disability: a prospective study of individuals with whiplash injury

PURPOSE

Emerging evidence suggests that perceptions of injustice negatively impact return to work following whiplash injury. The Injustice Experiences Questionnaire (IEQ) is a recently developed measurement tool that may be used to assess injury-related perceptions of injustice following injury. To date, although research has supported the predictive validity of the IEQ, a clinical cut off for interpreting this measure has not been established. Increased support for the validity and clinical interpretation of the IEQ represents a first step towards identifying patients that might benefit from targeted intervention to mitigate the impact of perceived injustice.

METHODS

The IEQ was completed by 103 whiplash-injured patients upon commencement and completion of a standardized multidisciplinary rehabilitation program. One year later, individuals reported on their employment activity, pain severity, and use of narcotics. A receiver operating characteristic (ROC) curve analysis was conducted to identify the post-treatment IEQ score that was optimally associated with unemployment status at the follow-up. Secondary ROC curve analyses examined IEQ scores best associated with high pain severity and narcotic use 1 year following treatment.

RESULTS

Results indicated that IEQ scores significantly discriminated individuals who returned and did not return to work at the follow-up. An IEQ score of 19 optimally identified participants in terms of follow-up employment status. IEQ scores at the end of treatment also discriminated individuals with high and low pain severity ratings and narcotic use status at the follow-up. Post-treatment IEQ scores of 18 and 20 optimally identified participants who had high pain severity ratings and who were using narcotics at the follow-up, respectively.

CONCLUSIONS

These results further support the validity of the IEQ and provide a guideline for its clinical interpretation in patients with persistent pain and disability following musculoskeletal injury. IEQ scores above the identified cut off may represent a barrier to work return and may warrant targeted intervention.

Anger regulation style, anger arousal and acute pain sensitivity: evidence for an endogenous opioid "triggering" model

Findings suggest that greater tendency to express anger is associated with greater sensitivity to acute pain via endogenous opioid system dysfunction, but past studies have not addressed the role of anger arousal. We used a 2 × 2 factorial design with Drug Condition (placebo or opioid blockade with naltrexone) crossed with Task Order (anger-induction/pain-induction or pain-induction/anger-induction), and with continuous Anger-out Subscale scores. Drug × Task Order × Anger-out Subscale interactions were tested for pain intensity during a 4-min ischemic pain task performed by 146 healthy people. A significant Drug × Task Order × Anger-out Subscale interaction was dissected to reveal different patterns of pain intensity changes during the pain task for high anger-out participants who underwent pain-induction prior to anger-induction compared to those high in anger-out in the opposite order. Namely, when angered prior to pain, high anger-out participants appeared to exhibit low pain intensity under placebo that was not shown by high anger-out participants who received naltrexone. Results hint that people with a pronounced tendency to express anger may suffer from inadequate opioid function under simple pain-induction, but may experience analgesic benefit to some extent from the opioid triggering properties of strong anger arousal.

Clinical features, anger management and anxiety: a possible correlation in migraine children

BACKGROUND

Psychological factors can increase severity and intensity of headaches. While great attention has been placed on the presence of anxiety and/or depression as a correlate to a high frequency of migraine attacks, very few studies have analyzed the management of frustration in children with headache. Aim of this study was to analyze the possible correlation between pediatric migraine severity (frequency and intensity of attacks) and the psychological profile, with particular attention to the anger management style.

METHODS

We studied 62 migraineurs (mean age 11.2 ± 2.1 years; 29 M and 33 F). Patients were divided into four groups according to the attack frequency (low, intermediate, high frequency, and chronic migraine). Pain intensity was rated on a 3-levels graduate scale (mild, moderate and severe pain). Psychological profile was assessed by Picture Frustration Study test for anger management and SAFA-A scale for anxiety.

RESULTS

We found a relationship between IA/OD index (tendency to inhibit anger expression) and both attack frequency (r = 0.328, p = 0.041) and intensity (r = 0.413, p = 0.010). When we analyzed the relationship between anxiety and the headache features, a negative and significant correlation emerged between separation anxiety (SAFA-A Se) and the frequency of attacks (r = -0.409, p = 0.006). In our patients, the tendency to express and emphasize the presence of the frustrating obstacle (EA/OD index) showed a positive correlation with anxiety level (“Total anxiety” scale: r = 0.345; p = 0.033).

CONCLUSIONS

Our results suggest that children suffering from severe migraine tend to inhibit their angry feelings. On the contrary, children with low migraine attack frequency express their anger and suffer from separation anxiety.

Associations between daily chronic pain intensity, daily anger expression, and trait anger expressiveness: an ecological momentary assessment study

Links between elevated trait anger expressiveness (anger-out) and greater chronic pain intensity are well documented, but pain-related effects of expressive behaviors actually used to regulate anger when it is experienced have been little explored. This study used ecological momentary assessment methods to explore prospective associations between daily behavioral anger expression and daily chronic pain intensity. Forty-eight chronic low back pain (LBP) patients and 36 healthy controls completed electronic diary ratings of momentary pain and behavioral anger expression in response to random prompts 4 times daily for 7 days. Across groups, greater trait anger-out was associated with greater daily behavioral anger expression (P<0.001). LBP participants showed higher levels of daily anger expression than controls (P<0.001). Generalized estimating equation analyses in the LBP group revealed a lagged main effect of greater behavioral anger expression on increased chronic pain intensity in the subsequent assessment period (P<0.05). Examination of a trait×situation model for anger-out revealed prospective associations between elevated chronic pain intensity and later increases in behavioral anger expression that were restricted largely to individuals low in trait anger-out (P<0.001). Trait×situation interactions for trait anger suppression (anger-in) indicated similar influences of pain intensity on subsequent behavioral anger expression occurring among low anger-in persons (P<0.001). Overlap with trait and state negative affect did not account for study findings. This study for the first time documents lagged within-day influences of behavioral anger expression on subsequent chronic pain intensity. Trait anger regulation style may moderate associations between behavioral anger expression and chronic pain intensity.

Suppression of anger and subsequent pain intensity and behavior among chronic low back pain patients: the role of symptom-specific physiological reactivity

Suppression of anger may be linked to heightened pain report and pain behavior during a subsequent painful event among chronic low back patients, but it is not clear whether these effects are partly accounted for by increased physiological reactivity during suppression. Chronic low back pain patients (N = 58) were assigned to Suppression or No Suppression conditions for a "cooperative" computer maze task during which a confederate harassed them. During baseline and maze task, patients' lower paraspinal and trapezius muscle tension, blood pressure and heart rate were recorded. After the maze task, patients underwent a structured pain behavior task (behaviors were videotaped and coded). Results showed that: (a) Suppression condition patients revealed greater lower paraspinal muscle tension and systolic blood pressure (SBP) increases during maze task than No Suppression patients (previously published results showed that Suppression condition patients exhibited more pain behaviors than No Suppression patients); (b) residualized lower paraspinal and SBP change scores were related significantly to pain behaviors; (c) both lower paraspinal and SBP reactivity significantly mediated the relationship between Condition and frequency of pain behaviors. Results suggest that suppression-induced lower paraspinal muscle tension and SBP increases may link the actual suppression of anger during provocation to signs of clinically relevant pain among chronic low back pain patients.

Pain-related emotions in early stages of recovery in whiplash-associated disorders: their presence, intensity, and association with pain recovery

OBJECTIVE

Psychological factors such as depression affect recovery after whiplash-associated disorders. This study examined the prevalence of pain-related emotions, such as frustration, anger, and anxiety, and their predictive value for postcrash pain recovery during a 1-year follow-up.

METHODS

A population-based prospective cohort study design was used. Self-reported pain-related depression, anxiety, fear, anger, and frustration were assessed using 100-mm visual analog scales (VASs) at 6 weeks after crash in 2986 persons with traffic-related whiplash-associated disorder. Multivariable logistic regression was used to assess the relationship between the intensity of these pain-related emotions and pain recovery at 4 and 12 months after crash. Pain was measured at all time points on a 100-mm VAS, and pain recovery was defined as a score of 10 or lower.

RESULTS

Pain-related frustration was the most intense, with a mean score of 52. Only 3% of the cohort reported having no pain-related frustration, and 4% reported no pain-related anxiety. Multivariable logistic regression models revealed that each pain-related emotion increased the risk of failing to recover (odds ratios for each point increase on the 100-mm VAS), ranging from 1.011 to 1.015. Specifically, with each 10-point increase in pain-related emotion, the odds of failing to achieve pain recovery at 4 months was increased by 14% (p < .001) for depression, 15% (p < .001) for anxiety, 11% (p < .001) for fear, 12% (p < .001) for anger, and 11% (p < .001) for frustration.

CONCLUSIONS

These findings suggest that it may be beneficial for health care providers to address emotional status related to pain in the first few weeks after a whiplash injury.

Interacting effects of trait anger and acute anger arousal on pain: the role of endogenous opioids

OBJECTIVE

Elevated trait anger (TRANG; heightened propensity to experience anger) is associated with greater pain responsiveness, possibly via associations with deficient endogenous opioid analgesia. This study tested whether acute anger arousal moderates the impact of TRANG on endogenous opioid analgesia.

METHODS

Ninety-four chronic low back pain (LBP) participants and 85 healthy controls received opioid blockade (8 mg of naloxone) or placebo in a randomized, counterbalanced order in separate sessions. Participants were randomly assigned to undergo either a 5-minute anger recall interview (ARI) or a neutral control interview across both drug conditions. Immediately after the assigned interview, participants engaged sequentially in finger pressure and ischemic forearm pain tasks. Opioid blockade effects were derived (blockade minus placebo condition pain ratings) to index opioid antinociceptive function.

RESULTS

Placebo condition TRANG by interview interactions (p values < .05) indicated that TRANG was hyperalgesic only in the context of acute anger arousal (ARI condition; p values < .05). Blockade effect analyses suggested that these hyperalgesic effects were related to deficient opioid analgesia. Significant TRANG by interview interactions (p values < .05) for both pain tasks indicated that elevated TRANG was associated with smaller blockade effects (less endogenous opioid analgesia) only in the ARI condition (p values < .05). Results for ischemic task visual analog scale intensity blockade effects suggested that associations between TRANG and impaired opioid function were most evident in LBP participants when experiencing anger (type by interview by TRANG interaction; p < .05).

CONCLUSIONS

Results indicate that hyperalgesic effects of TRANG are most prominent when acute anger is aroused and suggest that endogenous opioid mechanisms contribute.

Anger suppression and subsequent pain behaviors among chronic low back pain patients: moderating effects of anger regulation style

BACKGROUND

Suppression of anger is linked to subsequent pain intensity among chronic low back patients, but it is not clear whether anger regulation style (trait anger-out, anger-in) moderates these effects or if aroused anger accounts for links between anger regulation style and pain.

METHOD

Chronic low back pain patients (N=58) were assigned to Suppression or No Suppression conditions for a task with harassing confederate and then underwent structured pain behavior procedures. Spielberger Anger Expression Inventory tapped trait anger-out (AOS) and anger-in (AIS).

RESULTS

Regressions tested Emotion Regulation condition × AOS and AIS effects on outcomes. AOS was related to grimacing and sighing for Suppression condition patients. AIS was related negatively to guarding and bracing for Suppression condition patients. Anger report partly mediated effects for AOS and AIS.

CONCLUSIONS

Anger regulation style moderated effects of state anger suppression on subsequent pain behaviors, effects that were partly explained by aroused anger.

Anger suppression predicts pain, emotional, and cardiovascular responses to the cold pressor

BACKGROUND

Manipulated anger suppression has been shown to heighten pain and anger responses to pain.

PURPOSE

We examined whether individual differences in self-reported anger suppression predicted pain, anger, and blood pressure responses to acute pain.

METHODS

Healthy participants (N = 47) underwent an anger-provoking speech task followed by a cold pressor pain task. Participants reported their degree of suppression of thoughts and feelings related to the speech. Pain intensity ratings were obtained throughout the cold pressor. Self-reported anger, anxiety and positive emotion, as well as ratings of sensory, general distress, and anger-specific elements of pain were obtained following the cold pressor. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were recorded throughout.

RESULTS

Self-reported suppression predicted greater pain intensity ratings, perception of sensory and anger-specific elements of pain, and self-reported anger in response to the cold pressor. Associations between self-reported suppression and pain intensity and ratings of anger-specific elements of pain were statistically mediated by pain-induced changes in self-reported anger, whereas the effect of suppression on sensory pain ratings was not. Self-reported suppression was also correlated inversely with SBP responses to the cold pressor.

CONCLUSIONS

Consistent with an ironic process model and prior studies involving experimental manipulation of suppression, self-reported suppression of anger predicted greater pain intensity and perception of the anger-specific element of pain. Findings also suggest that suppression might attenuate homeostatic pressor responses to acute pain.

Appreciating the Predicament of Housebound Older Adults with Arthritis: Portrait of a Population

This paper draws a socio-demographic, physical, psychosocial, and behavioural profile of housebound older adults with arthritis and compares older adults with rheumatoid arthritis to those with osteoarthritis. Data from 125 housebound older adults with osteoarthritis (65%) or rheumatoid arthritis (35%) were compared to published samples and to population data using appropriate weighting. Respondents were mainly women, living alone, mean age 77 years (SD = 10.50). Symptoms of stiffness, fatigue, and pain intensity were moderate to severe, and a substantial proportion (51.4%) reported depression. Participants reported low levels of health behaviours such as exercise. Overall, older adults with rheumatoid arthritis were significantly younger, reported less pain and limitations, were more optimistic and satisfied with their social life, and had a higher self-efficacy than older adults with osteoarthritis. Home-based pain self-management programs should be constructed considering the unique profiles and needs of this population.

God image and happiness in chronic pain patients: the mediating role of disease interpretation

OBJECTIVE

The present study explored the role of the emotional experience of God (i.e., positive and negative God images) in the happiness of chronic pain (CP) patients. Framed in the transactional model of stress, we tested a model in which God images would influence happiness partially through its influence on disease interpretation as a mediating mechanism. We expected God images to have both a direct and an indirect (through the interpretation of disease) effect on happiness.

DESIGN

A cross-sectional questionnaire design was adopted in order to measure demographics, pain condition, God images, disease interpretation, and happiness. One hundred thirty-six CP patients, all members of a national patients' association, completed the questionnaires.

RESULTS

Correlational analyses showed meaningful associations among God images, disease interpretation, and happiness. Path analyses from a structural equation modeling approach indicated that positive God images seemed to influence happiness, both directly and indirectly through the pathway of positive interpretation of the disease. Ancillary analyses showed that the negative influence of angry God images on happiness disappeared after controlling for pain severity.

CONCLUSION

The results indicated that one's emotional experience of God has an influence on happiness in CP patients, both directly and indirectly through the pathway of positive disease interpretation. These findings can be framed within the transactional theory of stress and can stimulate further pain research investigating the possible effects of religion in the adaptation to CP.

Psychologic considerations in the management of oral surgical patients

Entering the often-sterile milieu that characterizes most surgical and presurgical environments sets into motion, for most patients, emotional or psychologic reactions. At times, these inner stirrings may manifest in the form of outward behaviors, such as expressions of anxiety or anger or verbalizations suggestive of depression. The essential psychologic issue is that undergoing any surgery--minor, major, elective, or urgent--is far from an emotionally neutral event for typical oral surgical patients.

Endogenous opioids may buffer effects of anger arousal on sensitivity to subsequent pain

Evidence suggests that anger and pain are related, yet it is not clear by what mechanisms anger may influence pain. We have proposed that effects of anger states and traits on pain sensitivity are partly opioid mediated. In this study, we test the extent to which analgesic effects of acute anger arousal on subsequent pain sensitivity are opioid mediated by subjecting healthy participants to anger-induction and pain either under opioid blockade (oral naltrexone) or placebo. Participants were 160 healthy individuals. A double-blind, placebo-controlled, between-subjects opioid blockade design is used, with participants assigned randomly to one of two drug conditions (placebo or naltrexone), and to one of two Task Orders (anger-induction followed by pain or vice versa). Results of ANOVAs show significant Drug Condition x Task Order interactions for sensory pain ratings (MPQ-Sensory) and angry and nervous affect during pain-induction, such that participants who underwent anger-induction prior to pain while under opioid blockade (naltrexone) reported more pain, and anger and nervousness than those who underwent the tasks in the same order, but did so on placebo. Results suggest that for people with intact opioid systems, acute anger arousal may trigger endogenous opioid release that reduces subsequent responsiveness to pain. Conversely, impaired endogenous opioid function, such as that found among some chronic pain patients, may leave certain people without optimal buffering from the otherwise hyperalgesic affects of anger arousal, and so may lead to greater pain and suffering following upsetting or angry events.

Anger management style moderates effects of attention strategy during acute pain induction on physiological responses to subsequent mental stress and recovery: a comparison of chronic pain patients and healthy nonpatients

OBJECTIVES

To examine whether high trait anger-out chronic low back (CLBP) patients would show exceptionally large symptom-specific lower paraspinal (LP) responses, compared with healthy nonpatients, during pain induction, a subsequent mental stressor, and recovery when they were urged to suppress awareness of pain and suffering.

METHODS

CLBP patients (n = 93) and nonpatients (n = 105) were assigned randomly to one of four attention strategy conditions for use during pain induction: sensory-focus, distraction, suppression, or control. All participants underwent a cold pressor, and then performed mental arithmetic. They completed the anger-out (AOS) and anger-in (AIS) subscales of the Anger Expression Inventory.

RESULTS

General Linear Model procedures were used to test Attention Strategy Condition x Patient/Nonpatient Status x AOS (or AIS) x Period interactions for physiological indices. Significant interactions were found such that: a) high trait anger-out patients in the Suppression condition seemed to show the greatest LP reactivity during the mental arithmetic followed by the slowest recovery compared with other conditions; b) high trait anger-out patients and nonpatients in the Suppression condition seemed to show the slowest systolic blood pressure recoveries compared with other conditions.

CONCLUSIONS

Results extend previous work by suggesting that an anger-out style moderates effects of how attention is allocated during pain on responses to and recovery from a subsequent mental stressor. Results provide further evidence that trait anger-out and trait anger-in among CLBP patients are associated with increased LP muscle tension during and after pain and mental stress.