Anger expression and pain: an overview of findings and possible mechanisms

Mechanisms of the Native American pain inequity: predicting chronic pain onset prospectively at 5 years in the Oklahoma Study of Native American Pain Risk

ABSTRACT

A pain inequity exists for Native Americans (NAs), but the mechanisms are poorly understood. The Oklahoma Study of Native American Pain Risk (OK-SNAP) addressed this issue and recruited healthy, pain-free NAs and non-Hispanic Whites (NHWs) to attend 2 laboratory visits and assessed mechanisms consistent with the biopsychosocial model of pain: demographics, physical variables, psychosocial factors, and nociceptive/pain phenotypes. Then participants were surveyed every 6 months to assess for chronic pain onset. Results at the 2-year follow-up found that NAs were ∼3x more likely than NHWs to develop chronic pain. Moreover, psychosocial factors (discrimination, stress, pain-related anxiety), cardiometabolic load (higher body mass index and blood pressure, lower heart rate variability), and impaired inhibition of spinal nociception partly mediated the pain inequity. The present study examined mechanisms of chronic pain at the 5-year follow-up for OK-SNAP. Results found that the NA pain inequity worsened-NAs were 4x more likely to develop chronic pain (OR = 4.025; CI = 1.966, 8.239), even after controlling for baseline age, sex assigned at birth, income, and education. Moreover, serial mediation models replicated paths from the 2-year follow-up that linked psychosocial variables, cardiometabolic load, and impaired inhibition of spinal nociception to chronic pain onset. Further, 2 new significant paths were observed. One linked discrimination, stress, sleep problems, and facilitated pain perception to increased pain risk. The other linked discrimination with higher spinal nociceptive threshold and pain risk. These results provide further evidence for a NA pain inequity and identify multiple psychosocial, cardiometabolic, and pronociceptive targets for primary interventions.

'Hidden' anger as a risk factor for operational health: An exploratory approach among French military personnel

Military personnel are repeatedly exposed to multiple stressors, and are sometimes characterized by high levels of anger. Evidence suggests that this anger can become dysfunctional, and impact the health status of populations chronically exposed to stress. In particular, rumination (understood as perseverative thoughts about a past event), provides a theoretical framework for investigating how anger may impact stress regulation abilities in military personnel declared fit for deployment. This exploratory study aimed therefore to examine the impact of the anger profile on psychological suffering in terms of burnout and post-traumatic stress disorder (PTSD), along with the reactivity of the autonomic nervous system, measured as cardiac variability. One hundred and seventeen French soldiers were tested before deployment to Operation BARKHANE. Anger rumination, burnout, and PTSD symptoms were assessed using questionnaires, and cardiac variability was measured as the questionnaires were completed. The results revealed two profiles related to anger trait and anger rumination. Burnout and PTSD scores were higher among military personnel with high levels of anger trait and rumination, and this group also had lower parasympathetic activity and flexibility after completing the questionnaires. These results suggest that there may be a link between an angry profile and psychological suffering, notably burnout and PTSD. Rumination could be involved in this link, as it is associated with poor adaptation to stress in a military context. Prospective researches including post-deployment will establish whether this ruminative response can account for the relationship between problematic anger, stress regulatory capacities and psychological health in military populations.

A network analysis on biopsychosocial factors and pain-related outcomes assessed during a COVID-19 lockdown

Psychological stress, social isolation, physical inactivity, and reduced access to care during lockdowns throughout a pandemic negatively impact pain and function. In the context of the first COVID-19 lockdown in Spain, we aimed to investigate how different biopsychosocial factors influence chiropractic patients' pain-related outcomes and vice-versa. A total of 648 chiropractic patients completed online questionnaires including variables from the following categories: demographics, pain outcomes, pain beliefs, impact of the COVID-19 pandemic, stress/anxiety and self-efficacy. Twenty-eight variables were considered in a cross-sectional network analysis to examine bidirectional associations between biopsychosocial factors and pain outcomes. Subgroup analyses were conducted to estimate differences according to gender and symptom duration. The greatest associations were observed between pain duration and pain evolution during lockdown. Participants' age, pain symptoms' evolution during lockdown, and generalized anxiety were the variables with the strongest influence over the whole network. Negative emotions evoked by the pandemic were indirectly associated with pain outcomes, possibly via pain catastrophizing. The network structure of patients reporting acute pain showed important differences when compared to patients with chronic pain. These findings will contribute to identify which factors explain the deleterious effects of both the pandemic and the restrictions on patients living with 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.

Interpersonal Emotion Dynamics in Couples With Somatic Symptom Disorder: Dyadic Coherence in Facial Temperature During Emotional Interactions

OBJECTIVE

Disturbances in emotional processes are commonly reported in patients with a somatic symptom disorder (SSD). Although emotions usually occur in social interactions, little is known about interpersonal emotion dynamics of SSD patients during their actual emotional encounters. This study examined physiological coherence (linkage) between SSD patients and their partners, and in healthy couples during their emotional interactions. Secondarily, we explored group-level relationships between participants' and their partners' subjective affect.

METHODS

Twenty-nine romantic couples (16 healthy and 13 SSD patient-couples) underwent a dyadic conversation task with neutral and anger-eliciting topics followed by a guided relaxation. Partners' cutaneous facial temperature was recorded simultaneously by functional infrared thermal imaging. Immediately after each condition, participants reported on their pain intensity, self-affect, and perceived partner-affect.

RESULTS

Emotional conditions and having a partner with an SSD significantly affected coherence amplitude on the forehead (F(2,54) = 4.95, p = .011) and nose tip temperature (F(2,54) = 3.75, p = .030). From baseline to anger condition, coherence amplitude significantly increased in the patient-couples, whereas it decreased in the healthy couples. Correlation changes between partners' subjective affect comparably accompanied the changes in physiological coherence in healthy and patient-couples.

CONCLUSIONS

Inability to reduce emotional interdependence in sympathetic activity and subjective affect during a mutual conflict observed in SSD patient-couples seems to capture emotion co-dysregulation. Interventions should frame patients' emotional experiences as embodied and social. Functional infrared thermal imaging confirms to be an ecological and reliable method for examining autonomic changes in interpersonal contexts.Registration Page: https://osf.io/8eyjr.

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.

Contemporary English Pain Descriptors as Detected on Social Media Using Artificial Intelligence and Emotion Analytics Algorithms: Cross-sectional Study

BACKGROUND

Pain description is fundamental to health care. The McGill Pain Questionnaire (MPQ) has been validated as a tool for the multidimensional measurement of pain; however, its use relies heavily on language proficiency. Although the MPQ has remained unchanged since its inception, the English language has evolved significantly since then. The advent of the internet and social media has allowed for the generation of a staggering amount of publicly available data, allowing linguistic analysis at a scale never seen before.

OBJECTIVE

The aim of this study is to use social media data to examine the relevance of pain descriptors from the existing MPQ, identify novel contemporary English descriptors for pain among users of social media, and suggest a modification for a new MPQ for future validation and testing.

METHODS

All posts from social media platforms from January 1, 2019, to December 31, 2019, were extracted. Artificial intelligence and emotion analytics algorithms (Crystalace and CrystalFeel) were used to measure the emotional properties of the text, including sarcasm, anger, fear, sadness, joy, and valence. Word2Vec was used to identify new pain descriptors associated with the original descriptors from the MPQ. Analysis of count and pain intensity formed the basis for proposing new pain descriptors and determining the order of pain descriptors within each subclass.

RESULTS

A total of 118 new associated words were found via Word2Vec. Of these 118 words, 49 (41.5%) words had a count of at least 110, which corresponded to the count of the bottom 10% (8/78) of the original MPQ pain descriptors. The count and intensity of pain descriptors were used to formulate the inclusion criteria for a new pain questionnaire. For the suggested new pain questionnaire, 11 existing pain descriptors were removed, 13 new descriptors were added to existing subclasses, and a new Psychological subclass comprising 9 descriptors was added.

CONCLUSIONS

This study presents a novel methodology using social media data to identify new pain descriptors and can be repeated at regular intervals to ensure the relevance of pain questionnaires. The original MPQ contains several potentially outdated pain descriptors and is inadequate for reporting the psychological aspects of pain. Further research is needed to examine the reliability and validity of the revised MPQ.

Anger as a Mechanism of Injustice Appraisals in Pediatric Chronic Pain

Mechanisms explaining the relationship between pain-related injustice appraisals and functional outcomes in youth with chronic pain have yet to be examined. In studies of adults, greater pain-related injustice is associated with worse depressive symptoms and greater pain through greater anger. No study to date has examined anger expression as a mediator in the relationships between pain-related injustice appraisals and physical and psychosocial functioning in youth with chronic pain. The current sample consisted of 385 youth with varied pain conditions (75% female, 88% White, M_age=14.4 years) presenting to a university-affiliated pain clinic. Patients completed self-report measures assessing anger expression (anger-out and anger-in), pain-related injustice, pain intensity, functional disability, and emotional, social, and school functioning. Bootstrapped mediation analyses indicated that only anger-out (indirect effect= -.12, 95% CI: -.21, -.05) mediated the relationship between pain-related injustice and emotional functioning, whereas both anger-out (indirect effect= -.17, 95% CI: -.27, -.09) and anger-in (indirect effect= -.13, 95% CI: -.09, -.001) mediated the relationship between pain-related injustice and social functioning. Neither mode of anger expression mediated the relationship between pain-related injustice and pain intensity, functional disability, or school functioning. Collectively, these findings implicate anger as one mechanism by which pain-related injustice impacts psychosocial outcomes for youth with chronic pain. Perspective: Anger expression plays a mediating role in the relationship between pain-related injustice appraisals and psychosocial outcomes for youth with chronic pain. Anger represents one target for clinical care to decrease the deleterious impact of pain-related injustice on emotional and social functioning.

The effect of alexithymia and depressive feelings on pain perception in somatoform pain disorder

OBJECTIVE

To investigate the relationship between alexithymia and depression and their influence on the subjective versus experimental pain perception in somatoform pain disorder.

METHODS

Three groups consisting of 40 patients with somatoform pain disorder, 40 patients with depression, and 40 healthy controls were matched. They completed questionnaires regarding alexithymia (TAS26) and depressive feelings (BDI-II). In addition, pain patients rated their subjective pain intensity (NRS). Quantitative sensory testings were conducted in all participants examining temperature (CPT, HPT) and mechanical (MPT, PPT) thresholds.

RESULTS

Analysis of variance showed that alexithymia was significantly increased in both patient groups compared to healthy controls, but with the highest amount in somatoform pain. Regression analyses confirmed that this finding was in part due to a high comorbidity of depressive feelings in both patient groups. We found a discrepancy between increased clinical pain ratings and elevated pressure pain thresholds, indicating a less intense mechanical pain perception in somatoform pain. Correlation analyses demonstrated a significant connection of subjective pain ratings and pressure pain thresholds with depressive feelings.

CONCLUSION

Contrary to the results of other experimental pain studies on chronic muskuloskeletal pain syndromes, we could not confirm central sensitization in somatoform pain disorder. Our findings place the somatoform pain disorder more in the direction of affective disorder such as depression. These findings may improve a better understanding of the disease and also have direct therapeutic implications. The high occurrence of alexithymia and depressive feelings in somatoform pain should be considered in diagnostic and therapeutic regimens of these patients.

Measuring anger in patients experiencing chronic pain - A systematic review

Anger is prevalent in chronic pain and has been associated with pain perception, disability, behavior and treatment outcome. Objectives were (1) to survey in the context of chronic pain the application (and omission) of validated anger self-report instruments, (2) to discuss the instruments found in the context of emotion theories and (3) to identify a possible instrument preference. A systematic search of textbooks and review articles was first performed on validated instruments designed to measure the cognitive, the motivational and the subjective feeling component of anger. Thereafter, a systematic review aimed at finding chronic pain studies from 2005 to 2019 reporting on these instruments. Textbooks and reviews listed 16 validated self-report anger measurement instruments. 28 papers applying four of these were identified and two new instruments were additionally detected. The State-Trait Anger Expression (STAXI) and its precursors were most commonly used. Studies on chronic low back pain patients prevailed. In conclusion, anger in chronic pain patients is reliably measurable at low cost with self-report tools. The STAXI-II qualifies best for this purpose based on its extensive validation history. The majority of instruments lack sufficient theoretical and psychometric adequacy. A more detailed exploration of the cognitive anger component in chronic pain patients in future research is recommended.

Developing a Japanese version of the Injustice Experience Questionnaire-chronic and the contribution of perceived injustice to severity of menstrual pain: a web-based cross-sectional study

Background

Menstrual pain causes low quality of life among women of reproductive age, and often interferes with daily activities. Perceived injustice is a cognition linked to adverse symptoms. The aims of this study were to develop a Japanese version of the Injustice Experience Questionnaire-chronic (IEQ-chr-J), and to examine if perceived injustice is associated with pain intensity and impairment from menstruation.

Methods

We investigated 130 Japanese women (aged 20–45 years) with menstrual pain in the past 3 months using online self-administered questionnaires. We examined the psychometric properties of the IEQ-chr-J including: structural validity; internal consistency; and test-retest reliability (intra-class correlation coefficients; ICC). Concurrent validity was examined by correlations among the IEQ-chr-J, the Pain Catastrophizing Scale (PCS), the Hospital Anxiety and Depression Scale (HADS), a numerical rating scale (NRS) for maximum/average menstrual pain, and the Brief Pain Inventory (BPI) pain interference domain. We used multivariable regression analysis to investigate the association between perceived injustice and severity of menstrual pain, after excluding 10 hormone drug users.

Results

The IEQ-chr-J showed sufficient validity and reliability (Cronbach’s α = 0.96, ICC 0.75, [95% confidence interval (CI): 0.61–0.88]. Pearson’s correlation coefficients for the IEQ-chr-J, PCS, HADS anxiety, HADS depression, NRS, and BPI pain interference ranged from 0.27–0.65. The IEQ-chr-J was correlated with impairment due to menstrual pain (ICC 0.36, 95% CI: 0.14–0.58), an independent diagnosis of endometriosis, anxiety, and depression, but not with maximum or average pain intensity.

Conclusions

The IEQ-chr-J has acceptable psychometric properties, and perceived injustice is associated with impairment from menstrual pain.

Electronic supplementary material

The online version of this article (10.1186/s13030-019-0158-z) contains supplementary material, which is available to authorized users.

State and trait anger and its expression in cluster headache compared with migraine: a cross-sectional study

BACKGROUND

Anger is involved in the emotional experience of pain. Individuals with migraine are more likely to hold their anger-in than controls. However, only one study evaluated anger in cluster headache (CH). The objective is to compare anger between migraine and CH patients.

METHODS

One hundred thirty-five migraine and 108 CH patients completed the State Trait Anger Expression Inventory (STAXI-2), composed of 7 subscales. State Anger measures the intensity of the individual's angry feelings at the time of testing. Trait Anger evaluates general predisposition to become angry. Anger Expression Out and Anger Expression In measure the extent to which anger could be overtly expressed or suppressed. Anger Control Out and Anger Control In evaluate how individual try to control the outward or inward expression of anger. Anger Expression Index is a general index.

RESULTS

CH patients have higher median scores than migraine patients in State Anger (46 vs 44, p = 0.012). CH patients have lower scores in Anger Control Out (44 vs 50, p = 0.016). In subgroup analysis, CH patients during the cluster period have higher scores than chronic migraine patients in State Anger (47 vs 44, p = 0.035), while CH patients in headache-free period did not differ from migraine patients.

CONCLUSIONS

Migraine and CH patients differ in state anger, indicating that CH patients experienced higher intensity of anger during the time of testing. These data add new information about emotional regulation in headache patients and could support the hypothesis of different emotional and behavioral responses to pain in migraine and CH patients.

Pilot field testing of the chronic pain classification for ICD-11: the results of ecological coding

BACKGROUND

A task force of the International Association for the Study of Pain (IASP) has developed a classification of chronic pain for the ICD-11 consisting of seven major categories. The objective was to test whether the proposed categories were exhaustive and mutually exclusive. In addition, the perceived utility of the diagnoses and the raters' subjective diagnostic certainty were to be assessed.

METHODS

Five independent pain centers in three continents coded 507 consecutive patients. The raters received the definitions for the main diagnostic categories of the proposed classification and were asked to allocate diagnostic categories to each patient. In addition, they were asked to indicate how useful they judged the diagnosis to be from 0 (not at all) to 3 (completely) and how confident they were in their category allocation.

RESULTS

The two largest groups of patients were coded as either chronic primary pain or chronic secondary musculoskeletal pain. Of the 507 patients coded, 3.0% had chronic pain not fitting any of the proposed categories (97% exhaustiveness), 20.1% received more than one diagnosis. After adjusting for double coding due to technical reasons, 2.0% of cases remained (98% uniqueness). The mean perceived utility was 1.9 ± 1.0, the mean diagnostic confidence was 2.0 ± 1.0.

CONCLUSIONS

The categories proved exhaustive with few cases being classified as unspecified chronic pain, and they showed themselves to be mutually exclusive. The categories were regarded as useful with particularly high ratings for the newly introduced categories (chronic cancer-related pain among others). The confidence in allocating the diagnoses was good although no training regarding the ICD-11 categories had been possible at this stage of the development.

Emotional State Can Affect Inflammatory Responses to Pain Among Rheumatoid Arthritis Patients: Preliminary Findings

In a novel pilot study, we investigated how emotional state is related to inflammatory responses to acute pain among women with rheumatoid arthritis. Nine women completed four 5-hour visits that varied only by manipulation of emotion (anger, sadness, happiness, vs. control); in each visit, acute pain was elicited, with blood draws at baseline, 10 minutes, 60 minutes, and 100 minutes post-pain. We examined the effects of within-subjects factors on circulating inflammatory biomarkers interleukin (IL)-6, IL-10, tumor necrosis factor-α, C-reactive protein, and cortisol. There was a main effect of state anger on IL-6, with higher reported anger associated with higher IL-6 across conditions. Further, there were several interactions between state emotion and condition. For example, when individuals reported higher state anger in the sadness condition compared to their own average, they showed higher levels of IL-6 and cortisol. Findings are discussed within a larger literature suggesting that mixed emotional states can contribute to psychological stress and inflammatory responses.

Typologies of intimate partner violence-maternal parenting and children's externalizing problems: The moderating effect of the exposure to other forms of family violence

Typologies of IPV and parenting practices in mothers who experienced police-reported IPV remain surprisingly unexplored, in addition to how those typologies are linked with children's externalizing problems. Using data from 162 Portuguese mother-child dyads with a police or child protection services referral of IPV, this study aimed to: (a) identify IPV-parenting typologies; (b) test the associations between typologies and children's externalizing problems, and (c) examine the moderating effect of children's exposure to other forms of family violence in those associations. Using a person-centered approach, two IPV-parenting typologies were found: a spillover typology, with high levels of physical, psychological, and sexual violence and high levels of harsh and inconsistent parenting practices; and a compartmentalized typology, with high levels of physical, psychological, and sexual violence and lower ineffective parenting practices. Results also showed that externalizing symptoms (reported by mothers and teachers) were significantly lower in children of mothers in the compartmentalized typology compared to those in the spillover typology. Children's direct exposure to other forms of family violence moderated this association. Findings suggested that children with a high exposure to other forms of family violence showed the highest levels of externalizing problems when their mothers were classified into the spillover typology, and they exhibited the lowest levels of externalizing problems when their mothers were classified in the compartmentalized typology.

Cognitive-affective depression and somatic symptoms clusters are differentially associated with maternal parenting and coparenting

BACKGROUND

Both depressive and somatic symptoms are significant predictors of parenting and coparenting problems. However, despite clear evidence of their co-occurrence, no study to date has examined the association between depressive-somatic symptoms clusters and parenting and coparenting. The current research sought to identify and cross-validate clusters of cognitive-affective depressive symptoms and nonspecific somatic symptoms, as well as to test whether clusters would differ on parenting and coparenting problems across three independent samples of mothers.

METHOD

Participants in Studies 1 and 3 consisted of 409 and 652 community mothers, respectively. Participants in Study 2 consisted of 162 mothers exposed to intimate partner violence. All participants prospectively completed self-report measures of depressive and nonspecific somatic symptoms and parenting (Studies 1 and 2) or coparenting (Study 3).

RESULTS

Across studies, three depression-somatic symptoms clusters were identified: no symptoms, high depression and low nonspecific somatic symptoms, and high depression and nonspecific somatic symptoms. The high depression-somatic symptoms cluster was associated with the highest levels of child physical maltreatment risk (Study 1) and overt-conflict coparenting (Study 3). No differences in perceived maternal competence (Study 2) and cooperative and undermining coparenting (Study 3) were found between the high depression and low somatic symptoms cluster and the high depression-somatic symptoms cluster.

CONCLUSIONS

The results provide novel evidence for the strong associations between clusters of depression and nonspecific somatic symptoms and specific parenting and coparenting problems. Cluster stability across three independent samples suggest that they may be generalizable. The results inform preventive approaches and evidence-based psychotherapeutic treatments.

Positive and Negative Affect Is Related to Experiencing Chest Pain During Exercise-Induced Myocardial Ischemia

OBJECTIVE

Silent myocardial ischemia is thought to be associated with worse cardiovascular outcomes due to a lack of perception of pain cues that initiate treatment seeking. Negative affect (NA) has been associated with increased pain reporting and positive affect (PA) with decreased pain reporting, but these psychological factors have not been examined within the context of myocardial ischemia. This study evaluated the associations between PA, NA, and chest pain reporting in patients with and without ischemia during exercise testing.

METHODS

A total of 246 patients referred for myocardial perfusion single-photon emission computed tomography exercise stress testing completed the positive and negative affect schedule-expanded version, a measure of PA and NA. Presence of chest pain and myocardial ischemia were evaluated using standardized protocols.

RESULTS

Logistic regression analyses revealed that for every 1-point increase in NA, there was a 13% higher chance for ischemic patients (odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.02 to 1.26) and an 11% higher chance in nonischemic patients (OR = 1.11; 95% CI = 1.03 to 1.19) to report chest pain. A significant interaction of PA and NA on chest pain reporting (β = 0.02; 95% CI = 0.002 to 0.031) was also observed; nonischemic patients with high NA and PA reported more chest pain (57%) versus patients with low NA and low PA (13%), with high NA and low PA (17%), and with high PA and low NA (7%).

CONCLUSIONS

Patients who experience higher NA are more likely to report experiencing chest pain. In patients without ischemia, high NA and PA was also associated with a higher likelihood of reporting chest pain. Results suggest that high levels of PA as well as NA may increase the experience and/or reporting of chest pain.

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.

Building a Biopsychosocial Conceptual Framework to Explore Pressure Ulcer Pain for Hospitalized Patients

Although pressure ulcers are a prevalent condition, pain associated with pressure ulcers is not fully understood. Indeed, previous studies do not shed light on the association between pressure ulcer stages and the experience of pain. Especially, pain characteristics of suspected deep tissue injury, which is a new category that was recently added by the National Pressure Ulcer Advisory Panel, are yet unknown. This is concerning because the incidence of pressure ulcers in hospitalized patients has increased exponentially over the last two decades, and health care providers are struggling to ensure providing adequate care. Thus, in order to facilitate the development of effective interventions, this paper presents a conceptual framework to explore pressure ulcer pain in hospitalized patients. The concepts were derived from a biopsychosocial model of pain, and the relationships among each concept were identified through a literature review. Major propositions are presented based on the proposed conceptual framework, which integrates previous research on pressure ulcer pain, to ultimately improve understanding of pain in hospitalized patients with pressure ulcers.

A psychological flexibility conceptualisation of the experience of injustice among individuals with chronic pain

Accumulating evidence suggests that the experience of injustice in patients with chronic pain is associated with poorer pain-related outcomes. Despite this evidence, a theoretical framework to understand this relationship is presently lacking. This review is the first to propose that the psychological flexibility model underlying Acceptance and Commitment Therapy (ACT) may provide a clinically useful conceptual framework to understand the association between the experience of injustice and chronic pain outcomes. A literature review was conducted to identify research and theory on the injustice experience in chronic pain, chronic pain acceptance, and ACT. Research relating injustice to chronic pain outcomes is summarised, the relevance of psychological flexibility to the injustice experience is discussed, and the subprocesses of psychological flexibility are proposed as potential mediating factors in the relationship between injustice and pain outcomes. Application of the psychological flexibility model to the experience of pain-related injustice may provide new avenues for future research and clinical interventions for patients with pain.

SUMMARY POINTS

• Emerging research links the experience of pain-related injustice to problematic pain outcomes. • A clinically relevant theoretical framework is currently lacking to guide future research and intervention on pain-related injustice. • The psychological flexibility model would suggest that the overarching process of psychological inflexibility mediates between the experience of injustice and adverse chronic pain outcomes. • Insofar as the processes of psychological inflexibility account for the association between injustice experiences and pain outcomes, methods of Acceptance and Commitment Therapy (ACT) may reduce the impact of injustice of pain outcomes. • Future research is needed to empirically test the proposed associations between the experience of pain-related injustice, psychological flexibility and pain outcomes, and whether ACT interventions mitigate the impact of pain-related injustice on pain outcomes.

Psychosocial factors and central sensitivity syndromes

Central sensitivity syndromes (CSSs) represent a heterogeneous group of disorders (e.g., fibromyalgia [FM], irritable bowel syndrome [IBS], chronic headache, temporomandibular disorders [TMDs], pelvic pain syndromes) that share many common symptoms, with persistent pain being the most prominent feature. Although the etiology and pathophysiology of CSSs are currently incompletely understood, central sensitization has emerged as one of the significant mechanisms. Given that there are currently no known cures for CSSs, people living with these disorders must learn to cope with and manage their symptoms throughout their lives. Medical interventions alone have not proven to be sufficient for helping people with CSSs manage their symptoms. A biopsychosocial perspective that considers the ways that biological, psychological, and social factors work independently and jointly to affect a person's experience is the most effective conceptualization and guide for effective treatment. In this article, we discuss several psychological and social features that may influence the experience of a person with CSS and their symptom management, regardless of their specific diagnosis. We highlight the longitudinal aspect of adjustment to illness, the distinction between psychosocial factors as causes of symptoms versus modifiers and perpetuators of symptoms, dispel the notion that all patients with the same diagnosis are a homogeneous group (the "patient-uniformity myth"), and acknowledge the importance of environmental and situational context on symptom management for individuals with any CSS.

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.

Aggression, impulsivity, and suicide risk in benign chronic pain patients - a cross-sectional study

OBJECTIVES

The objective of this study was to investigate the role that psychopathological dimensions as overt aggression and impulsivity play in determining suicide risk in benign chronic pain patients (CPPs). Furthermore we investigated the possible protective/risk factors which promote these negative feelings, analyzing the relationship between CPPs and their caregivers.

METHODS

We enrolled a total of 208 patients, divided into CPPs and controls affected by internistic diseases. Assessment included collection of sociodemographic and health care data, pain characteristics, administration of visual analog scale (VAS), Modified Overt Aggression Scale (MOAS), Barratt Impulsiveness Scale Version 11 (BIS), Hamilton Depression Rating Scale (HDRS), and a caregiver self-administered questionnaire. All variables were statistically analyzed.

RESULTS

A significant difference of VAS, MOAS-total/verbal/auto-aggression, HDRS-total/suicide mean scores between the groups were found. BIS mean score was higher in CPPs misusing analgesics. In CPPs a correlation between MOAS-total/verbal/auto-aggression with BIS mean score, MOAS with HDRS-suicide mean score and BIS with HDRS-suicide mean scores were found. The MOAS and BIS mean scores were significantly higher when caregivers were not supportive.

CONCLUSION

In CPPs, aggression and impulsivity could increase the risk of suicide. Moreover, impulsivity, overt aggression and pain could be interrelated by a common biological core. Our study supports the importance of a multidisciplinary approach in the CPPs management and the necessity to supervise caregivers, which may become risk/protective factors for the development of feelings interfering with the treatment and rehabilitation of CPPs.

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.

'I am absolutely shattered': the impact of chronic low back pain on Australian Aboriginal people

BACKGROUND

Aboriginal people in Australia have been uniquely identified as less susceptible to chronic low back pain (CLBP) disability when compared to non-Aboriginal populations, reportedly due to cultural beliefs about pain. A qualitative, culturally secure research approach was used to explore this assumption.

METHODS

In-depth interviews were undertaken with 32 Aboriginal men and women with CLBP in regional and remote areas of Western Australia. Interviews were conducted collaboratively with male and female Aboriginal co-investigators, and with the support of local Aboriginal community organizations. A primary focus was to investigate the impact of CLBP from the perspective of Aboriginal people living with the condition.

RESULTS

The experience of CLBP was found to be multidimensional, impacting on activities of daily life, employment, sport and family participation, emotional and cultural well-being.

CONCLUSIONS

Contrary to previous assumptions, CLBP is profoundly disabling for some Aboriginal people and a priority health concern. Issues of gender, cultural obligations and the emotional consequences of CLBP are important consideration for health care. These findings, and the contextual approach used to gain an in-depth understanding of CLBP, may be relevant to populations elsewhere.

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.

Perceived injustice in injured workers: analysis of public responses to an injured worker who took Workers' Compensation Board employees hostage

INTRODUCTION

Injured workers' perceived injustice can contribute to retaliatory, aggressive actions. Research also shows a relationship between persistent pain, anger and aggressive, maladaptive coping.

AIMS

We took the unique opportunity afforded by a workers compensation board (WCB) hostage taking incident to address four questions: (i) What contemporary values, beliefs, and potential behaviours about the WCB system are reflected in the online postings of other claimants (or family members of claimants) in response to the hostage taking incident? (ii) To what degree do the narratives of people who posted online (PWP) in response to this incident, demonstrate the theme of perceived injustice and support retaliatory actions? (iii) How accurate is the information relayed by PWP about the WCB system where the hostage taking occurred? (iv) What is the quality and the public utility of the information this WCB makes available to the public through on-line posting?

METHODS

We thematically analysed comments posted on a national news website in response to the hostage-taking. We focused on posted narratives from people who stated that they had personal involvement with WCB. We also assessed the accuracy of the comments about WCB made in these narratives against the information available on the WCB website. A standardized assessment tool was used to determine the readability and accessibility of the WCB website.

FINDINGS

Emergent themes were: retribution, perceived systemic mistreatment, justice/injustice, empathy, disbelief, and loss. There were many inaccurate beliefs about the Workers' Compensation Board. The overall quality of readability and accessibility of the website was low.

CONCLUSION

Narratives indicated perceived procedural injustice attributed to a flawed and uncaring compensation system. Inaccurate beliefs about WCB and poor quality of the public website may have contributed to suffering, miscommunication and perceptions of unjust, systemic mistreatment. Findings support a relationship between perceived injustice and aggressive retaliatory action.

Forms and Functions of Emotions: Matters of Emotion–Cognition Interactions

This article clarifies my current and seemingly ever-changing position on issues relating to emotions. The position derives from my differential emotions theory and it changes with new empirical findings and with insights from my own and others’ thinking and writing. The theory distinguishes between first-order emotions and emotion schemas. For example, it proposes that first-order negative emotions are attributable mainly to infants and young children in distress and to older individuals in emergency or highly challenging situations. Emotion schemas are defined as emotion feelings interacting with cognition in motivating the decision making and actions of everyday life.

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.

Chronic fatigue syndrome, fibromyalgia, and related illnesses: a clinical model of assessment and intervention

A clinically informative behavioral literature on chronic fatigue syndrome (CFS) and fibromyalgia (FM) has emerged over the past decade. The purpose of this article is to (a) define these conditions and their less severe counterparts, i.e., unexplained chronic fatigue (UCF) and chronic widespread pain; (b) briefly review the behavioral theory and intervention literature on CFS and FM; and (c) describe a user-friendly clinical model of assessment and intervention for these illnesses. The assessments described will facilitate understanding of the somewhat unusual and puzzling somatic presentations that characterize these patients. Using an individualized cognitive-behavioral approach the mental health clinician can offer significant help to these often stigmatized and medically underserved patients.

The effect of perceived racial discrimination on bodily pain among older African American men

OBJECTIVES

We examined the extent to which experiences of racial discrimination are associated with bodily pain reported by African American men.

METHODS

The study sample consisted of 393 African American male veterans who responded to a national survey of patients aged 50-75 who received care from the Veterans Health Administration (VHA). Veterans were surveyed by mail, with a telephone follow-up. The response rate for African Americans in the sample was 60.5%. Pain (assessed using the bodily pain subscale of the 36-item short-form health survey), experiences of discrimination, employment, education, and income were obtained through the survey. Age, race, and mental health comorbidities were obtained from VA administrative data. Multiple regression analysis adjusting for item non-response (via imputation) and unit non-response (via propensity scores and weighting) was used to assess the association between racial discrimination and likelihood of experiencing moderate or severe pain over the past 4 weeks.

RESULTS

Experiences of racial discrimination were associated with greater bodily pain (beta = -0.25, P < 0.0001), even after controlling for socioeconomic and health-related characteristics.

CONCLUSION

Perceived racial discrimination was associated with greater pain among a sample of older African American male patients in the VA. Additional research is needed to replicate this finding among other populations of African Americans.

Development of the Ghent Multidimensional Somatic Complaints Scale

The present study aimed at developing a new scale that operationalizes a hierarchical model of somatic complaints. First, 63 items representing a wide range of symptoms and sensations were compiled from somatic complaints scales and emotion literature. These complaints were rated by Belgian students (n = 307) and Belgian adults (n = 603). Exploratory factor analyses identified a gastrointestinal, cardiorespiratory, pain, temperature regulation, and fatigue factor. Next, the number of complaints was reduced to 18. Second, the short scale, called the Ghent Multidimensional Somatic Complaints Scale (GMSC), was administered to Belgian students (n = 735), Belgian adults (n = 664), and Turkish adults (n = 222). Confirmatory factor analysis confirmed that a higher-order model with five first-order and one second-order factor fitted best. Regression analyses demonstrated that the first-order factors were differentially related to anxiety, depression, anger, age, and gender. In sum, the GMSC scale offers the possibility to assess individual differences in somatic complaints from a hierarchical perspective.