Emotional Awareness and Expression Therapy for Chronic Pain: Rationale, Principles and Techniques, Evidence, and Critical Review

The Impact of Stressful Life Events on Centralized Pain and Pain Intensity: A Combined Model Examining the Mediating Roles of Anger and Perceived Injustice Among Racially Minoritized Adults With Chronic Pain

Stressful life events are highly associated with chronic pain. Yet, research is needed to identify the psychological mechanisms that link life adversity and pain, especially studies that test comprehensive models, recruit racially diverse samples, and measure varied pain-related symptoms. This study examined the relationship between stressful life events and pain in a racially diverse sample and tested the potential mediating roles of both anger and perceived injustice. Both centralized pain symptoms and pain intensity were the outcomes. Analyses consisted of 2 cross-sectional, mediation models among 673 adults with self-reported chronic pain who were racially diverse (Black: n = 258, Latine: n = 254, Asian American: n = 161). The results indicated a positive relationship between stressful life events and centralized pain symptoms (b = 2.53, P < .001) and pain intensity (b = .20, P < .001). In parallel mediation analyses, anger (b = .91, 95% CI = .67, 1.17) and perceived injustice (b = .86, 95% CI = .64, 1.11) acted as partial mediators on centralized pain symptoms. Also, anger (b = .05, 95% CI = .03, .08) and perceived injustice (b = .11, 95% CI = .08, .14) acted as full mediators on pain intensity. The combined psychosocial variables accounted for 51% of centralized pain symptoms and 26% of pain intensity. The findings suggest that psychosocial factors are significantly associated with pain outcomes. Future research is needed to investigate exposure to adversity in life, anger, and perceived injustice together as psychosocial mechanisms of pain symptoms. PERSPECTIVE: Among racially minoritized adults with chronic pain, this article presents empirical evidence that stressful life events, anger, and perceived injustice are associated with centralized pain symptoms and pain intensity. This could guide psychological intervention to focus on anger and perceived injustice, especially when addressing centralized pain.

Profiles of Trauma Exposure Type and Its Associations With Pain-Related Outcomes Among Adults With Chronic Pain: A 2-Year Longitudinal Study

Individuals with chronic pain report disproportionally higher rates of trauma, yet it is unclear whether different types of trauma (eg, sexual, accidental trauma) are associated with worse pain outcomes. The present study sought to 1) identify subgroups of people with chronic pain based on trauma type, and 2) determine whether subgroups differ in terms of pain characteristics over a 2-year period. Individuals with chronic pain (N = 1,451) participated in an online study and completed self-report questionnaires at baseline, 3-, 12-, and 24-month follow-up. Trauma was assessed via the Life Events Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Pain intensity and interference were measured via the Brief Pain Inventory, and pain distribution was evaluated using the Widespread Pain Index. Latent class analyses produced a 3-class solution consisting of individuals with high and diverse trauma (16.3%), high sexual trauma (18.4%), and low/accidental trauma (57.1%) with the rest of the sample endorsing no trauma history (8.2%). After controlling for key demographic variables and baseline outcome levels, individuals in the high- and diverse trauma group endorsed higher levels of pain severity and interference at the 3- and 12-month follow-ups compared with the group with no trauma (P < .01). Additionally, relative to the no trauma group, individuals in the high sexual trauma group reported higher levels of pain interference and more widespread pain at the 3-month follow-up (P < .05). The findings underscore the importance of screening for trauma and suggest that the type and variety of trauma experienced may be relevant to pain-related outcomes. PERSPECTIVE: This article highlights how an individual's unique trauma history may be related to their current pain experience. Knowledge of the type and frequency of past trauma may have relevant clinical implications for the treatment of chronic pain.

Moving toward affective immunology: Legacy and future directions

The term "affective immunology" has recently been used to denote a field focused on the interplay between affective processes (including mood states, specific emotions, and regulatory processes) and various aspects of immune function. The overarching goals of this commentary are a) to provide historical underpinnings of this field with a focus on the profound impact of the work of Janice Kiecolt-Glaser, who is further honored in this special issue, b) to review important off-shoots of her legacy work in this domain, and c) to highlight important future directions for the field. Kiecolt-Glaser's work laid much of the foundation for affective immunology, with groundbreaking research related to depression, hostility and dyadic interactions, loneliness, and other affective patterns, often in the context of holistic models, novel experimental designs, and interventions. Her former mentees (and many of their mentees) have carried on her legacy in these domains, in ways that continue to advance appreciation of how affective processes relate to immune function. There are numerous remaining questions for the field to pursue, including better understanding of the role of emotion regulation, emotional reactivity and recovery, restorative processes, affective variability, and developmental and dynamic social processes. Such work will require greater use of longitudinal and within-person approaches and/or examination of processes in daily life, as well as models that account for interactive and reciprocal processes and which integrate behavior, social context, sociocultural factors, individual differences, and other aspects of health. As more work in these domains continues, building on Kiecolt-Glaser's rich legacy, we move toward the emergence of affective immunology as an important subfield in the domain of psychoneuroimmunology, one which will offer more nuanced understanding of the role of affective processes in immune health.

Somatic symptoms in school refusal: a qualitative study among children, adolescents, and their parents during the COVID-19 pandemic

School refusal (SR) is commonly associated with somatic symptoms that are temporally related to school attendance. Abdominal pain, headache, vomiting, and musculoskeletal pain are frequently encountered and are usually not caused by a physical disease. School refusers, parents and health care workers are often puzzled by these impairing symptoms. In this qualitative study, we assessed somatic symptoms in a population encompassing both school refusers and their parents. We aimed at better understanding experiences and strategies in the management of these debilitating symptoms, while also investigating the journey of these symptoms and their behavioral consequences on the said population. We conducted qualitative interviews both within an Integrated Youth Health Care Unit in Paris and through a French parent-led support group improving care for school refusers. We interviewed 19 young persons with SR (aged 6-21 years old) and 20 parents. Using the Grounded Theory, three themes were identified: (1) somatic symptoms' journey in four phases (emergence, coping, crisis, and disappearance in the context of school dropout); (2) their deconstruction, indicating the patients' emotional state; and (3) their management through self-care practices as well as increased emotional and body awareness. Some parents, who could portray similar symptoms at a younger age, mentioned familial pattern of heightened emotional and sensorial sensitivity as a possible cause. Findings suggested that somatic symptoms in SR offer an insight into the patients' emotional state. We recommend that psychotherapies targeting somatic symptoms could be further assessed in SR, along with educational content aimed at increasing emotional literacy in schools and health care settings.

Outpatient interdisciplinary multimodal pain treatment programme for patients with chronic musculoskeletal pain: a longitudinal cohort study

PURPOSE

To describe the outcomes of an interdisciplinary multimodal pain treatment (IMPT) for chronic musculoskeletal pain (CMP) patients up until 12 months post-treatment.

MATERIALS AND METHODS

Data were gathered during routine clinical practice during a 3-year period (2019-2021) at six Dutch rehabilitation centres. Assessments included patient-reported outcome measures for multiple domains including disability, pain and fatigue. Longitudinal data were analysed using repeated-measures models and by quantifying responder rates.

RESULTS

Included were 2309 patients with a mean age of 43.7 (SD 12.9) years, of which 73% female. All outcomes showed significant improvements at each timepoint. At discharge, large effect sizes were found for disability, average and worst pain, fatigue and health-related quality of life. Improvements were largely sustained at 12-months. Relatively large proportions of patients had clinically relevant improvements after treatment (pain-related disability: 60%; average pain: 52%; worst pain: 37.4%; work capacity: 50%; concentration: 50%; fatigue: 46%). Patients who received a treatment extension showed further improvements for all outcome measures, except average pain.

CONCLUSIONS

At group level, all outcomes significantly improved with mainly large effect sizes. The results were mostly sustained. The proportion of patients showing clinically relevant improvements tends to be larger than previously reported for mixed CMP patients.

Emotional Awareness and Expression Therapy vs Cognitive Behavioral Therapy for Chronic Pain in Older Veterans: A Randomized Clinical Trial

Importance

Chronic pain is common and disabling in older adults, and psychological interventions are indicated. However, the gold standard approach, cognitive-behavioral therapy (CBT), produces only modest benefits, and more powerful options are needed.

Objectives

To evaluate whether emotional awareness and expression therapy (EAET) is superior to CBT for treatment of chronic pain among predominantly male older veterans and whether higher baseline depression, anxiety, or posttraumatic stress disorder (PTSD) symptoms-key targets of EAET-moderate treatment response.

Design, Setting, and Participants

This 2-arm randomized clinical trial was conducted from May 16, 2019, to September 14, 2023, in the US Department of Veterans Affairs Greater Los Angeles Healthcare System. The trial included a racially and ethnically diverse group of veterans aged 60 to 95 years with at least 3 months of musculoskeletal pain.

Interventions

Emotional awareness and expression therapy or CBT, conducted concurrently, each presented as one 90-minute individual session followed by eight 90-minute group sessions.

Main Outcomes and Measures

The primary outcome was Brief Pain Inventory pain severity (range, 0 to 10) from baseline to posttreatment (week 10, primary end point) and 6-month follow-up. Secondary outcomes included Patient Reported Outcomes Institute Measurement System Anxiety, Depression, Fatigue, General Life Satisfaction (NIH Toolbox), Pain Interference, and Sleep Disturbance Short Forms, Patient Global Impression of Change (PGIC), and Satisfaction with Therapy and Therapist Scale-Revised. A subset of participants completed the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). All analyses were for the intention-to-treat population and included all randomized participants.

Results

Among 126 randomized participants (66 in the EAET group and 60 in the CBT group; mean [SD] age, 71.9 [5.9] years; 116 [92%] male), 111 (88%) completed posttreatment, and 104 (82%) completed the 6-month follow-up. The EAET was superior to CBT for the primary outcome of reduction in pain severity at posttreatment (estimate, -1.59 [95% CI, -2.35 to -0.83]; P < .001) and follow-up (estimate, -1.01 [95% CI, -1.78 to -0.24]; P = .01). A greater percentage of participants in EAET vs CBT had clinically significant (at least 30%) pain reduction (63% vs 17%; odds ratio, 21.54 [95% CI, 4.66-99.56]; P < .001) at posttreatment. In addition, EAET was superior to CBT on 50% pain reduction (35% vs 7%; odds ratio, 11.77 [95% CI, 2.38-58.25]; P = .002), anxiety (estimate, -2.49 [95% CI, -4.30 to -0.68]; P = .006), depression (estimate, -3.06 [95% CI, -5.88 to -0.25]; P = .03), general life satisfaction (estimate, 1.23 [95% CI, 0.36-2.10]; P = .005), PTSD symptoms (estimate, -4.39 [95% CI, -8.44 to -0.34]; P = .03), PGIC score (estimate, 1.46 [95% CI, 0.77-2.15]; P < .001), and global treatment satisfaction (estimate, 0.28 [95% CI, 0.12-0.45]; P < .001) at posttreatment. Higher baseline depression (estimate, -1.55 [95% CI, -0.37 to 2.73]; P < .001), anxiety (estimate, -1.53 [95% CI, -2.19 to -0.88]; P < .001), and PTSD symptoms (estimate, -1.69 [95% CI, -2.96 to -0.42]; P = .009) moderated greater reduction in pain severity after EAET but not CBT.

Conclusions and Relevance

The results of this randomized clinical trial suggest that EAET may be a preferred intervention for medically and psychiatrically complex patients with pain. The societal burden of chronic pain could be improved by further incorporating the principles of EAET into mainstream clinical pain medicine.

Trial Registration

ClinicalTrials.gov Identifier: NCT03918642.

Interstitial cystitis-an imbalance of risk and protective factors?

Interstitial cystitis (IC) presents as a chronic pain condition with variable combinations of symptoms depending on the species and individual patient. It is diagnosed by the presence of lower urinary tract signs and symptoms in combination with a variety of comorbid health problems, a history of life adversities, and the absence of other conditions that could cause the lower urinary tract signs. IC occurs naturally in humans and cats as a dimensional condition, with patients presenting with mild, moderate, and severe symptoms. Most patients appear to recover without specific treatment. A number of rodent models of IC have been used to study its causes and treatments. Unfortunately, current therapies generally fail to ameliorate IC symptoms long-term. The recent classification of IC as a chronic primary pain disorder calls for a rethinking of current clinical and research approaches to it. Beginning when a patient encounters a clinician, precipitating, perpetuating, and palliating risk factors can be addressed until a cause or reliably effective therapy is identified, and identifying predisposing and preventive factors can inform epidemiological studies and health promotion interventions. Predisposing, precipitating, and perpetuating risk factors, including environmental, psychological, and biological, increase the activity of the central threat response system (CTRS), which plays a clinically important role in IC symptoms. Studies in cats and rodent models have revealed that environmental enrichment (EE), in the absence of bladder-directed therapies, leads to amelioration of IC symptoms, implying a central role for the CTRS in symptom precipitation and perpetuation. Conceptually moving the source of IC pain to the brain as a motivational state rather than one resulting from peripheral nociceptive input offers both clinicians and researchers novel opportunities to improve care for patients with IC and for researchers to use more ecologically valid rodent models. It may even be that IC results from an excess of risk to protective factors, making this imbalance a targetable cause rather than a consequence of IC.

[Emotional competence of patients with chronic pain : A self- and third-party assessment]

RESEARCH QUESTION

The aim of the study is to assess the status quo of emotional competence in people with chronic pain. How do patients experience themselves regarding to their ability to perceive, express, and regulate emotions? And does this assessment coincide with the assessment of emotional competence (EC) by mental health professionals?

METHODS

The study took place in the context of interdisciplinary multimodal pain therapy at an outpatient clinic in N = 184 adult German-speaking individuals with non-cancer-related chronic pain. EC was assessed at the end of therapy using the self- and third-party assessment scales of the Emotional Competence Questionnaire. The external assessment was performed by the mental health team. Standard scores were created using the norm sample provided by questionnaires. These were analyzed descriptively and inferentially.

RESULTS

Self-perceived EC was average (Mself_total = 99.31; SD = 7.78). The mental health professionals predominantly rated the emotional competence of the patients significantly lower (Mexternal_total = 94,70; SD = 7,81; F(1.179) = 35,73; p < 0.001; η2 = 0.17). Emotional expressivity, as a component of EC, was externally rated as below average (Mexpressivity_external = 89.14, SD = 10.33).

DISCUSSION

Patients with chronic pain rate themselves as unimpaired in terms of their daily emotional awareness, expression, and regulation abilities. At the same time, mental health professionals rate these same individuals as significantly less emotionally competent. The question remains open as to what extent the divergent assessments can be explained by assessment bias.

The effectiveness of a combined exercise and psychological treatment programme on measures of nervous system sensitisation in adults with chronic musculoskeletal pain - a systematic review and meta-analysis

BACKGROUND

Quantitative sensory testing (QST) offers information regarding underlying mechanisms contributing to chronic pain (CP) in adults with musculoskeletal disorders. This review examined the use of QST measures in adults with CP following participation in a combined exercise and psychological intervention.

METHODS

The review was conducted in accordance with the PRISMA guidelines. Five databases were searched from inception to November 2022. All study designs which evaluated the effects of a combined exercise and psychological treatment on measures of nervous system sensitivity in adults with chronic musculoskeletal pain were included.

RESULTS

A total of 13 studies met the selection criteria, 10 of which were included in a meta-analysis. Local pressure pain thresholds were the most frequently used measure (n = 12 studies). Meta-analysis revealed statistically significantly improvements in favour of the combined exercise and psychological intervention group, compared to a control group, for local pressure pain threshold measures [SMD = 0.44, 95% CI 0.08-0.81, I2 = 84%], pain intensity scores [SMD=-0.89, 95% CI -1.66- -0.13, I2 = 94%] and the Central Sensitisation Inventory [SMD=-0.69, 95% CI -1.37- -0.02, I2 = 87%]. There were no significant differences found between groups for remote pressure pain thresholds, temporal summation or conditioned pain modulation.

CONCLUSIONS

The results suggest that a combined exercise and psychological intervention may lead to greater improvements in local pressure pain threshold, pain intensity and Central Sensitisation Inventory scores when compared to a control intervention in adults with CP, however these findings must be interpreted with caution as a large degree of heterogeneity was present in these results (I2: 84-94%). Further large, longitudinal studies are required using standardised QST measurement procedures and patient reported outcome measures to explore changes in nervous system sensitisation.

TRIAL REGISTRATION

This systematic review is registered with PROSPERO, ID Number CRD42022380464.

Emotion-Focused Psychodynamic Interview for People with Chronic Musculoskeletal Pain and Childhood Adversity: A Randomized Controlled Trial

Childhood adversity and emotional conflicts are associated with the presence and severity of chronic musculoskeletal pain (CMP), yet common treatments for CMP do not address such risk factors. We developed a single session, emotion-focused psychodynamic interview, based on Emotional Awareness and Expression Therapy and Intensive Short-term Psychodynamic Therapy, and we tested the interview's effects on pain-related outcomes and potential psychological mediators in a randomized, controlled trial. Adults (N = 91; ages 21-70, M = 44.64; 87.9% women) reporting CMP and at least 3 adverse childhood experiences completed measures at baseline and 6-week follow-up. Participants were randomized to immediate interview or waitlist control conditions. The 90-minute interview was conducted via videoconference, and the interviewer elicited disclosure of adversities and conflicts, linked these with pain, and encouraged the experience and expression of adaptive emotions. Analyses indicated that conditions did not differ significantly on change in pain severity; however, compared to control, the interview led to a significantly greater reduction in pain interference (P = .016, ηp2 = .05) and a similar trend for anxiety (P = .058, ηp2 = .04). The interview also significantly changed several potential mediators: pain-related anxiety (P = .008, ηp2 = .06), pain controllability (P = .016, ηp2 = .06), and psychological (P < .001, ηp2 = .15) and brain attributions (P = .022, ηp2 = .05) for pain. Participants viewed the interview as very valuable. We conclude that addressing childhood adversities and conflicts in a psychodynamic interview is beneficial for people with CMP. PERSPECTIVE: This study found that, compared to waitlist control, a 90-minute, remotely-administered, emotion-focused, psychodynamic interview improved pain interference, and anxiety among adults with chronic musculoskeletal pain and childhood adversity. Intensive emotional work can be done in a single session to the benefit of patients with chronic musculoskeletal pain.

Video telehealth emotional awareness and expression therapy for older U.S. military veterans with chronic pain: A pilot study

OBJECTIVES

Emotional Awareness and Expression Therapy (EAET) targets trauma and emotional conflict to reduce or eliminate chronic pain, but video telehealth administration is untested. This uncontrolled pilot assessed acceptability, feasibility, and preliminary efficacy of group-based video telehealth EAET (vEAET) for older veterans with chronic musculoskeletal pain.

METHODS

Twenty veterans were screened, and 16 initiated vEAET, delivered as one 60-minute individual session and eight 90-minute group sessions. Veterans completed posttreatment satisfaction ratings and pain severity (primary outcome), pain interference, anxiety, depression, functioning, social connectedness, shame, and anger questionnaires at baseline, posttreatment, and 2-month follow-up.

RESULTS

Satisfaction was high, and veterans attended 7.4 (SD = 0.6) of 8 group sessions; none discontinued treatment. Veterans attained significant, large reductions in pain severity from baseline to posttreatment (p < .001, Hedges' g = -1.54) and follow-up (p < .001, g = -1.20); 14 of 16 achieved clinically significant (≥ 30%) pain reduction, and 3 achieved 90-100% pain reduction. Secondary outcomes demonstrated significant, medium-to-large improvements.

CONCLUSIONS

In this small sample, vEAET produced better attendance, similar benefits, and fewer dropouts than in-person EAET in prior studies. Larger, controlled trials are needed.

CLINICAL IMPLICATIONS

Group vEAET appears feasible and highly effective for older veterans with chronic pain.

Implications for a mindfulness-enhanced positive affect induction: A brief commentary toward acute pain management

Over the past decade research has increased on dynamics between mindfulness, positive affect, and pain. While there have been studies examining the direct use of positive psychology for pain management, few have examined the use of a specific mindfulness-enhanced positive affect induction (i.e. a singular brief technique engendering mindfulness and strong positive affect) toward acute pain and pain flare management. This topical commentary discusses the need for such a technique toward bolstered gold-standard interventions, related studies, and possible future directions for acute and post-surgical pain management. Future research is encouraged to build from prior research on loving-kindness meditation and examine novel, brief mindfulness-enhanced positive affect inductions for acute pain management.

Are Sexual Assaults Related to Functional Somatic Disorders? A Cross-Sectional Study

An increasing number of sexual assaults (SAs) are being reported. This study investigated associations between SA and FSD, conceptualized as bodily distress syndrome (BDS), and five functional somatic syndromes (FSSs): chronic widespread pain (CWP), irritable bowel (IB), chronic fatigue (CF), multiple chemical sensitivity (MCS), and whiplash-associated disorder (WAD). Participants (n = 7493) from the population-based cohort Danish Study of Functional Disorders (DanFunD) completed questionnaires on FSD, emotional distress, SA, and sociodemographics. Risk ratios (RRs) for each FSD and emotional distress were calculated in nine models with SA as the primary exposure using generalized linear models with binomial family and log link and were adjusted for other potential risk factors. The results showed that SA was associated with single-organ FSD (RR = 1.51; 95% CI = 1.22-1.87), multi-organ FSD (RR = 3.51; 95% CI = 1.89-6.49), CWP (RR = 1.28; 95% CI = 0.83-1.98), IB (RR = 2.00; 95% CI = 1.30-3.07), CF (RR = 1.81; 95% CI = 1.42-2.32), WAD (RR = 2.62; 95% CI = 1.37-5.03), MCS (RR = 3.04; 95% CI = 1.79-5.17), emotional distress (RR = 1.75; 95% CI = 1.21-2.54), and health anxiety (RR = 1.65; 95% CI = 1.10-2.46). Overall, SA victims experienced significantly more somatic symptoms than individuals not exposed to SA. Adjusting for physical and emotional abuse did not change the observed associations. Our results suggest a large impact of SA on the overall somatic and mental health of SA victims. Due to the cross-sectional study design, further studies are required.

Understanding the gaps in headache and migraine treatment with psychological and behavioral interventions: A narrative review

OBJECTIVE

In this narrative review, we summarize relevant literature pertaining to psychosocial risk factors for headache and migraine progression, current behavioral and psychological treatments, and consider promising treatments.

BACKGROUND

Headache and migraine are common and associated with significant burden and disability. Current treatments targeting psychosocial risk factors show modest outcomes and do not directly address the impact of early life adversity, including the development of maladaptive emotional processing. An intervention that could address these factors and include components of current evidence-based interventions may lead to improved outcomes.

METHODS

We searched PubMed and Google Scholar for articles through December 2022. Search terms included headache, migraine, psychological interventions, behavioral interventions, cognitive-behavioral therapy, mindfulness, psychiatric comorbidities, adverse childhood experiences, trauma, and emotional processing.

RESULTS

Trauma and childhood adversity show a correlation with headache and migraine progression. Developmental adversity and trauma interfere with adaptive emotional processing, which may worsen headache and migraine symptoms, while adaptive ways of experiencing emotions are shown to improve symptoms. Current behavioral and psychological interventions, such as cognitive-behavioral and mindfulness therapies, are effective treatments for headache, but they produce small to medium effect sizes and do not directly address the impact of trauma and emotional conflicts-common factors that contribute to chronicity and disability, especially among certain subpopulations of headache patients such as those with migraine. Thus, there exists a gap in current treatment.

CONCLUSION

There is a gap in headache and migraine treatment for those patients who have a history of trauma, childhood adversity, and maladaptive emotional processing. We suggest that an integrated psychological treatment that includes components of current evidence-based interventions and addresses gaps by focusing on processing trauma-related emotions may improve chronic and debilitating symptoms.

"I don't have chronic back pain anymore": Patient Experiences in Pain Reprocessing Therapy for Chronic Back Pain

In a recently published randomized controlled trial, two-thirds of the patients receiving a novel psychological treatment, pain reprocessing therapy (PRT), reported elimination or near-elimination of chronic back pain. The mechanisms of PRT and related treatments remain poorly understood but are hypothesized to center on pain reappraisal, fear reduction, and exposure-potentiated extinction. Here, we investigated treatment mechanisms from the participants' perspective. A sample of 32 adults with chronic back pain who received PRT completed semi-structured posttreatment interviews about their treatment experiences. The interviews were analyzed with multiphase thematic analysis. The analyses identified 3 major themes reflecting participants' understanding of how PRT led to pain relief: 1) reappraisal to reduce fear of pain, which included guiding participants to relate to pain as a helpful indicator, overcoming pain-related fear and avoidance, and reconceptualizing pain as a "sensation;" 2) the link between pain, emotions, and, stress, which included gaining insight into these connections and resolving difficult emotions; and 3) social connections, which included patient-provider alliance, therapist belief in the treatment model, and peer models of recovery from chronic pain. Our findings support the hypothesized mechanisms of PRT centered on pain reappraisal and fear reduction, but also highlight additional processes from the participants' perspective, including a focus on emotions and relationships. This study underscores the value of qualitative research methods in illuminating the mechanisms of novel pain therapies. PERSPECTIVE: This article presents participants' perspectives on their experience engaging in a novel psychotherapy for chronic pain, PRT. Through pain reappraisal, linking pain, emotions, and stress, and connecting with their therapist and peers, many participants reported an elimination or near-elimination of their chronic back pain with therapy.

[Emotions in chronic pain : Changes in the course of day clinic interdisciplinary multimodal pain therapy]

RESEARCH QUESTION

The present study examined the extent to which emotional experience and emotional competence (EC) change in people with chronic pain during interdisciplinary multimodal pain treatment (IMPT).

METHODS

The study included N = 184 adult German-speaking individuals with non-cancer-related chronic pain. They completed a day clinic IMPT. The frequency of specific emotions (anger, etc.) and EC was assessed at three measurement time points using the Questionnaire for Emotion-Specific Self-Assessment of Emotional Competencies (ERSQ-ES) and the Emotional Competency Questionnaire (ECQ). The course results were analyzed descriptively, inferentially, and using linear regression.

RESULTS

Positive emotions were experienced more frequently (effect size r = 0.40; p < 0.001) and negative emotions less frequently (r = 0.39, p < 0.001) at end of therapy. The experience of anger decreased particularly strongly (r = 0.52; p < 0.001). Self-assessed EC did not change during the IMPT (χ2ECQ_total (2) = 0.09; p = 0.956). EC largely explained the variance in the frequency experience of positive (R2 = 0.468) and negative emotions (R2 = 0.390).

DISCUSSION

Improvements in patient-reported frequencies of positive and negative emotions during IMPT were demonstrated. Further research should validate these results using a control group. Even though no explicit increase in competence was perceivable for the studied subjects, EC had a high predictive value for emotion frequency. Future therapy designs and evaluations should focus more on changes of emotional experience.

Innovative treatment formats, technologies, and clinician trainings that improve access to behavioral pain treatment for youth and adults

Chronic pain is prevalent across the life span and associated with significant individual and societal costs. Behavioral interventions are recommended as the gold-standard, evidence-based interventions for chronic pain, but barriers, such as lack of pain-trained clinicians, poor insurance coverage, and high treatment burden, limit patients' ability to access evidenced-based pain education and treatment resources. Recent advances in technology offer new opportunities to leverage innovative digital formats to overcome these barriers and dramatically increase access to high-quality, evidenced-based pain treatments for youth and adults. This scoping review highlights new advances. First, we describe system-level barriers to the broad dissemination of behavioral pain treatment. Next, we review several promising new pediatric and adult pain education and treatment technology innovations to improve access and scalability of evidence-based behavioral pain treatments. Current challenges and future research and clinical recommendations are offered.

Psychophysiologic Symptom Relief Therapy (PSRT) for Post-acute Sequelae of COVID-19

Objective

To determine if psychophysiologic symptom relief therapy (PSRT) will reduce symptom burden in patients suffering from post-acute sequelae of COVID-19 (PASC) who had mild/moderate acute COVID-19 disease without objective evidence of organ injury.

Patients and Methods

Twenty-three adults under the age of 60 with PASC for at least 12 weeks following COVID-19 infection were enrolled in an interventional cohort study conducted via virtual platform between May 18, 2021 and August 7, 2022. Participants received PSRT during a 13 week (approximately 44 hour) course. Participants were administered validated questionnaires at baseline and at 4, 8, and 13 weeks. The primary outcome was change in somatic symptoms from baseline, measured using the Somatic Symptom Scale-8 (SSS-8), at 13 weeks.

Results

The median duration of symptoms prior to joining the study was 267 days (IQR: 144, 460). The mean SSS-8 score of the cohort decreased from baseline by 8.5 (95% CI: 5.7-11.4), 9.4 (95% CI: 6.9-11.9), and 10.9 (95% CI: 8.3-13.5) at 4, 8, and 13 weeks respectively (all p<.001). Participants also experienced statistically significant improvements across other secondary outcomes including changes in dyspnea, fatigue, and pain (all p<.001).

Conclusion

PSRT may effectively decrease symptom burden in patients suffering from PASC without evidence of organ injury. The study was registered on clinicaltrials.gov (NCT04854772).

Determining Profiles of Pain-Specific and General Emotion Regulation Skills and Their Relation to 12-Month Outcomes Among People With Chronic Pain

Difficulties with pain-specific emotion regulation (ER; eg, pain catastrophizing, pain acceptance) are associated with poor pain outcomes. Less is known about how general ER relates to pain outcomes, or the extent to which pain-specific and general ER interact. In a sample (N = 1,453) of adults with chronic pain, the current study used latent profile analysis to identify subgroups of people with distinct pain-specific and general ER profiles, and determined how subgroup membership at baseline related to pain severity, pain interference, depression and anxiety symptoms at 12-month follow-up. Four groups were identified: 1) general ER difficulties only (29.6%); 2) pain-specific and general ER difficulties (26.3%); 3) skillful pain-specific and general ER (24.6%); 4) pain-specific ER difficulties only (19.4%). Controlling for auto-correlation and demographic covariates, those with pain-specific and general ER difficulties had the worst outcomes in all domains. Membership to other groups did not differentiate between pain severity or interference outcomes; those skillful in pain-specific and general ER had the lowest depression and anxiety symptoms at 12 months. General ER difficulties are common among adults with chronic pain and raise relative risk when paired with pain-specific ER difficulties. Findings offer potential directions for individualizing pain psychology treatment. PERSPECTIVE: This article shows that people with chronic pain have different sets of strengths and difficulties when it comes to regulating emotions related and/or unrelated to the experience of pain itself. Understanding an individual's unique constellation of emotion regulation skills and difficulties might help personalize the psychological treatment of pain.

Traumatic Life Experience and Pain Sensitization: Meta-analysis of Laboratory Findings

OBJECTIVES

Psychological trauma often co-occurs with pain. This relationship has been explored using laboratory pain measures; however, findings have been mixed. Previous studies have limited operationalization of trauma (eg, posttraumatic stress disorder) or pain (eg, pain thresholds), which may contribute to conflicting results. Further, prior reviews likely underrepresent trauma experiences among people who are not receiving clinical care, limiting generalizability.

MATERIALS AND METHODS

We systematically reviewed the existing literature on the relationship between psychological trauma (eg, car accidents, sexual assault, childhood abuse, neglect) and laboratory pain (ie, quantitative sensory testing measures of pain threshold, intensity, summation, modulation), using inclusive criteria. The direction of the relationship between psychological trauma and pain sensitivity was evaluated, and moderation by purported pain mechanism (ie, pain detection, suprathreshold pain, central sensitization, inhibition) was explored.

RESULTS

Analyses were conducted using 48 studies that provided 147 effect sizes. A multivariate random-effects model with robust variance estimation resulted in a small but statistically significant overall effect size of g=0.24 (P=0.0002), reflecting a positive association between psychological trauma and enhanced laboratory pain sensitivity. Upon examination of mechanistic moderators, this relationship appears driven by effects on pain detection (g=0.28, P=0.002) and central sensitization (g=0.22, P=0.04). While effect sizes were similar across all moderators, effects on suprathreshold pain and inhibition were not statistically significant.

DISCUSSION

Findings demonstrate an overall pattern of trauma-related pain enhancement and point to central sensitization as a key underlying mechanism.

Chronic Pain in Older Adults: A Neuroscience-Based Psychological Assessment and Treatment Approach

Chronic pain remains a serious healthcare challenge, particularly for older adults who suffer substantial disability and are susceptible to serious risks from pain medications and invasive procedures. Psychotherapy is a promising option for older adults with chronic pain, since it does not contribute to medical or surgical risks. However, standard psychotherapies for chronic pain, including cognitive-behavioral therapy (CBT), acceptance and commitment therapy, and mindfulness-based interventions, produce only modest and time-limited benefits for older adults. In this article, we describe a novel, evidence-based psychological assessment and treatment approach for older adults with chronic pain, including a detailed case example. The approach begins with reviewing patients' pain, psychosocial, and medical histories to elicit evidence of a subtype of chronic pain called centralized (primary, nociplastic, or psychophysiologic) pain, which is highly influenced and may even be caused by life stress, emotions, and alterations in brain function. Patients then undertake a novel psychotherapy approach called emotional awareness and expression therapy (EAET) that aims to reduce or eliminate centralized pain by resolving trauma and emotional conflicts and learning healthy communication of adaptive emotions. Our published preliminary clinical trial (n = 53) indicated that EAET produced statistically significant and large effect size advantages over CBT in pain reduction and marginally greater improvements in pain interference than CBT for older adults with chronic musculoskeletal pain. Geriatric mental healthcare providers may learn this assessment and treatment approach to benefit many of their patients with chronic pain.

Internet-based emotional awareness and expression therapy for somatic symptom disorder: A randomized controlled trial

OBJECTIVE

Somatic symptom disorder (SSD) is commonly encountered in health care settings. Cognitive-behavioural treatments have been most extensively studied, but they tend to have small effects of temporary duration. Emotional awareness and expression therapy (EAET) is a newly developed treatment for SSD, targeting emotional processing of trauma and conflict as a mechanism of symptom change. In an earlier uncontrolled study of self-guided, internet-administrated EAET (I-EAET), we found substantial reductions in somatic symptoms, prompting the need for a randomized controlled trial of I-EAET.

METHODS

We conducted a 2-arm RCT, comparing 10-week I-EAET (n = 37) to a waitlist control (WL; n = 37). Primary outcomes were reductions of somatic symptoms (PHQ-15) and pain intensity (BPI-4) at post-treatment, with a 4-month evaluation of effect duration. We also analysed emotional processing (EPS-25) and depression (PHQ-9) as possible mediators of I-EAET's effects.

RESULTS

Compared to controls, I-EAET significantly reduced somatic symptoms at both post-treatment and follow-up. I-EAET also reduced pain, depression, insomnia, and anxiety at post-treatment, but these effects were not retained at follow-up. As hypothesized, a facet of emotional processing partially mediated the treatment effect on somatic symptoms, even when controlling for depression.

CONCLUSIONS

Although treatment effects were smaller than in the previous uncontrolled trial, I-EAET is a promising treatment for SSD, with a minority of patients (around 20%) experiencing substantial clinical improvement. The benefits of I-EAET are partially mediated by improved emotional processing. Future research should identify and target patients who respond best to I-EAET and develop tailored treatment to enhance treatment effects. (Preregistered at clinicaltrials.gov: NCT04751825.).

Facing Pain Together: A Randomized Controlled Trial of the Effects of Facebook Support Groups on Adults With Chronic Pain

Despite the popularity and affordances of social media groups for people with chronic conditions, there have been few controlled tests of the effects of these groups. This randomized controlled superiority trial examined the effects of Facebook groups on pain-related outcomes and tested whether a professional-led group leads to greater effects than a support group alone. We randomly assigned 119 adults with chronic pain to one of two Facebook group conditions: a standard condition (n = 60) in which participants were instructed to offer mutual support, or a professional-led condition (n = 59) in which the investigators disseminated empirically-supported, socially-oriented psychological interventions. Four groups were run (2 standard, 2 professional-led), each lasting 4 weeks and containing approximately 30 participants. Measures were administered at baseline, post-intervention, and 1-month follow-up. Across conditions, participants improved significantly in primary outcomes (pain severity and interference; medium-large effects) and a secondary outcome (depressive symptoms; small-medium effect), and they retained their outcomes 1 month after the groups ended. The 2 conditions did not differ on improvements. Overall, this study supports the use of social media groups as an additional tool to improve chronic pain-related outcomes. Our findings suggest that professional intervention may not have added value in these groups and that peer support alone may be driving improvements. Alternatively, the psychosocial intervention components used in the current study might have been ineffective, or more therapist direction may be warranted. Future research should examine when and how such guidance could enhance outcomes. PERSPECTIVE: Findings from this randomized trial support the use of both standard and professional-led Facebook groups as an accessible tool to enhance the lives of adults with chronic pain. This article provides direction for how to improve social media groups to optimize outcomes and satisfaction for more users.

"Pain, Stress, and Emotions": Uncontrolled trial of a single-session, telehealth, emotional awareness and expression therapy class for patients with chronic pain

Objectives

Trauma- and emotion-focused chronic pain interventions, particularly Emotional Awareness and Expression Therapy (EAET), show much promise for reducing pain and improving functioning. We developed a novel, single-session, telehealth-delivered EAET class ("Pain, Stress, and Emotions"; PSE) and tested it on adults with chronic pain of mixed etiology.

Methods

After an initial developmental phase, we conducted an uncontrolled trial, providing PSE to 74 individuals with chronic pain (63.5% female; 64.9% White; 60.8% with pain duration >5 years) in four class administrations. Participants completed self-report measures (primary outcomes: pain intensity and pain interference) at baseline and multiple follow-ups to 12 weeks. Linear mixed-models examined changes over time, and effect sizes were calculated on change from baseline to 4-week (primary endpoint) and 12-week follow-ups. The trial was registered with clinicaltrials.gov (NCT05014126).

Results

Participants reported high satisfaction with the PSE class. Pain intensity showed a significant, medium reduction across time (p < .001; d = 0.60 at 4 weeks); one-quarter of participants had clinically meaningful pain reduction (≥30%). Pain interference had a large reduction (p < .001; d = 0.74). There were significant but smaller improvements in most secondary outcomes (ds = 0.15 to 0.55; ps < .01). Effects were generally maintained or increased at 12-week follow-up. Higher education and baseline ambivalence over emotional expression predicted greater pain reductions.

Conclusions

People taking this EAET class had reduced pain severity and interference and improvements in other pain-related outcomes. The single-session, telehealth class holds promise as an easily delivered, efficient, and potentially impactful intervention for some patients with chronic pain, although controlled trials are needed.

Defining pain-validation: The importance of validation in reducing the stresses of chronic pain

Purpose

To validate an individual's feelings or behaviour is to sanction their thoughts or actions as worthy of social acceptance and support. In contrast, rejection of the individual's communicated experience indicates a denial of social acceptance, representing a potential survival threat. Pain-invalidation, though ill-defined, appears to be a fundamental component of psychosocial stress for people with chronic pain. As such, the aim of this paper was to define pain-validation and outline its importance for those with chronic pain.

Methods

The pain-validation construct was defined using themes inherent in the narratives of those with chronic pain, as identified in a previously published systematic search and thematic analysis, together with examination of additional literature on pain-validation in the clinical context.

Results

We present a construct definition, proposing that pain-validation must necessarily include: (i) belief that the pain experience is true for the individual, (ii) acceptability of the individual's expressions of pain, and (iii) communication of belief and acceptability to the individual experiencing pain. Further, we outline the importance of pain-validation as a protective factor and means of reducing many of the psychosocial stresses of chronic pain; for example, by indicating social support for pain-coping, buffering negative emotions, and re-enforcing unity and shared identity.

Implications

The role of pain-validation in the current era of pain management intervention is discussed. Adhering to interventions that involve cognitive and behavioural change is often difficult. Acknowledging and validating the acceptability of the patient's pain experience in the early stages of pain management may, therefore, be a key component of intervention that encourages compliance to the treatment plan and achieving therapeutic goals.

Systematic description of an interdisciplinary multimodal pain treatment programme for patients with chronic musculoskeletal pain, using the TIDieR checklist

OBJECTIVE

To provide a thorough and systematic description of an interdisciplinary multimodal pain treatment programme (IMPT) for patients with chronic musculoskeletal pain (CMP), using the TIDieR checklist as a guide.

RESULTS

The main goal of the 'Centre for Integral Rehabilitation (CIR) Excellent' IMPT is to improve daily functioning, participation and quality of life of patients with CMP by helping them to adapt their behaviour so as to better manage their symptoms. A combination of physical and psychosocial treatment methods is employed, including Emotional Awareness and Expression Therapy (EAET), Pain Neuroscience Education (PNE), Acceptance and Commitment Therapy (ACT), graded activity, exposure in vivo, and experiential learning through physical training. The interdisciplinary treatment team comprises physiotherapists, psychologists and a physiatrist. The programme lasts 10 weeks (61 h in total) and consists of three phases: a start (Week 1), education (Weeks 2-3), and skills learning phase (Weeks 4-10). Patients come in twice a week and participate in 2-4 sessions (3-4 h) per treatment day. The programme consists of both individual (physical and mental coaching) and group sessions (education, movement and behaviour outdoors/indoors). Individualisation through personal goal-setting is an important characteristic of the treatment, as well as frequent interdisciplinary consultation between care providers.

A Call for Interdisciplinary Collaboration to Promote Musculoskeletal Health: The Creation of the International Musculoskeletal Mental and Social Health Consortium (I-MESH)

Despite increasing recognition of psychosocial factors in musculoskeletal conditions, its impact on reducing the global toll of musculoskeletal symptoms has been only incremental. It is time to bring together clinicians and researchers with heterogeneous backgrounds, unified by a commitment to reduce the global impact of musculoskeletal illness by addressing mental and social health factors. In 2020, we initiated the International Musculoskeletal Mental and Social Health Consortium. Our current key priority areas are: (1) Develop best practices for uniform terminology, (2) Understand barriers to mental and social health care for musculoskeletal conditions, (3) Develop clinical and research resources. The purpose of this paper is to render a call to interdisciplinary collaboration on the psychological aspects of musculoskeletal health. We believe this international interdisciplinary collaboration is pivotal to the advancement of the biopsychosocial model of musculoskeletal care and has the potential to improve the health of individuals with musculoskeletal conditions globally.

Sustaining optimal performance when the stakes could not be higher: Emotional awareness and resilience in emergency service personnel (with learnings for elite sport)

Emergency services personnel are a high stress occupation, being frequently confronted with highly consequential stressors and expected to perform: without fault; under high pressure; and in unpredictable circumstances. Research often invokes similarities between the experiences of emergency services personnel and elite athletes, opening up the possibility of transferring learnings between these contexts. Both roles involve genuine risks to emotional wellbeing because their occupations involve significant stress. Similarly, both roles face obstacles and injury, and their "success" is dependent on high-quality execution of their skills under pressure. As such, both occupations are required to have resilience and effective coping abilities to ensure psychological well-being. Researchers suggest emotional awareness may be a key variable in the management and maintenance of resilience. This study: (1) explored the experiences of emergency services personnel; (2) characterised connections between emotional awareness and resilience; and (3) reflected on the ways these findings can be extrapolated to elite athletes. We analysed 11 interviews with emergency services personnel. Participants identified resilience as crucial when coping with stress, however, many defined resilience as remaining unaffected by stress rather than, for example, managing and responding to it. Participants defined emotional awareness as understanding their emotions, and they recognised associated benefits for coping, resilience, and burnout. Nevertheless, most participants did not engage in practices to improve their emotional awareness. Barriers, such as maladaptive beliefs and help-seeking stigma, interfered with participants' ability to cultivate emotional awareness, to promote resilience. In contrast, some participants described profound improvements in resilience and coping following the cultivation of emotional awareness. This finding illustrates that systemic change must target the individual, team, and organisation to correct misperceptions about resilience, emotional awareness, and psychological help-seeking. Developing emotional awareness may help emergency services personnel and other high stress occupations like elite athletes process difficult experiences and enhance their resilience, promoting well-being, and career longevity.

Individuals with both higher recent negative affect and physical pain have higher levels of C-reactive protein

Conceptualizing physical pain and negative affect as potentially interactive, we hypothesized that higher levels of peripheral inflammatory markers would be observed consistently only among individuals with both higher negative affect and pain symptomatology. Participants were generally healthy midlife adults from the Bronx, NY (N ​= ​212, M_age ​= ​46.77; 60.8% Black, 25.5% Hispanic/Latina/o) recruited as part of a larger study. Key measures were: reported pain intensity and pain interference at baseline, recent negative affect averaged from self-reports 5x/day for 7 days, and peripheral inflammatory markers (C-reactive protein [CRP] and a composite cytokine measure based on seven cytokines). Controlling for age, BMI, gender, and education, recent negative affect significantly interacted with both pain variables to explain variance in CRP, with higher CRP levels observed only in individuals with both higher negative affect and either higher pain intensity or pain interference. These findings contribute to an emerging literature suggesting that negative affect, pain, and inflammation are related in important and complex ways.

A review of the treatment of functional neurological disorder with intensive short-term dynamic psychotherapy

The purpose of this article was to raise awareness of an under-recognized but well-supported treatment for Functional Neurological Disorders (FND) termed Intensive Short-term Dynamic Psychotherapy (ISTDP). There has been significant interest in the role of psychological mechanisms in FND onset and maintenance with specific evidence for maladaptive emotional processing. We outline how this supports the theoretical basis for ISTDP as an option in FND treatment and undertake a literature review of the current evidence base. We describe the application of ISTDP to FND illustrated through direct therapy transcripts. We conclude with reflections on the strengths and limitations of ISTDP as well as recommendations regarding future research.

Eliciting emotional expressions in psychodynamic psychotherapies using telehealth: a clinical review and single case study using emotional awareness and expression therapy

The COVID-19 pandemic and ensuing social distancing requirements resulted in an abrupt transition in the provision of most mental healthcare to telehealth; yet it was, at first, unclear whether patients' emotional expressions - of great import to the success of many psychodynamic therapies - could be facilitated using teletherapy. This article first presents a targeted literature review focused on emotional expressions in psychotherapy and implementing psychodynamic therapy over telehealth and then describes our clinical experience transitioning a psychodynamically-informed, evidence-based, and experiential group treatment for chronic pain, emotional awareness and expression therapy (EAET), to video telehealth at VA Greater Los Angeles Healthcare System. We discuss barriers we encountered in our implementation of EAET over video telehealth but also illustrate the ultimate success of the approach using verbatim excerpts from our therapeutic work, which aim to demonstrate the potential to facilitate powerful emotional expressions over video telehealth when conducting a psychodynamically-informed treatment. We examine the possible applications for video telehealth to maintain emotionally focused, psychodynamic psychotherapy administration and enhance its teaching and training. Although we describe limitations of our specific approach, ultimately, our experience supports the potential efficacy of experiential, emotion-focused psychodynamic therapies in a telehealth setting.

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.

A Scoping Review and Proposed Framework for Coping in Youth With a History of Psychological Trauma and Chronic Pain

OBJECTIVE

Psychological trauma (e.g., abuse, neglect) and posttraumatic stress symptoms (PTSS) commonly occur in pediatric pain populations and may be related to various maladaptive coping strategies, which may in turn affect short- and long-term pain-related outcomes in youth. Accordingly, the current scoping review and conceptual framework seeks to identify important gaps in the field's current understanding of how coping impacts outcomes in youth who have experienced trauma/PTSS and pediatric chronic pain and explores avenues for future investigation.

METHODS

A scoping review of the literature was performed in Medline, Embase, Cochrane Library, PsycInfo, and Sociological Abstracts. Eligibility criteria included pediatric populations experiencing chronic pain, trauma, adverse childhood events, and/or PTSS and associated coping mechanisms. Nine research papers were selected and used to support the conceptual framework. The framework builds upon the work of Compas et al.'s' model of control-based coping (Compas et al., 2006; Compas & Harding Thomsen, 1999) and outlines the potential effects of trauma and/or PTSS and pain on coping and pain-related outcomes (e.g., pain chronicity, functional outcomes) in pediatric chronic pain populations.

RESULTS

A history of chronic pain and psychological trauma and/or PTSS in youth may contribute to increased risk for maladaptive coping and in turn, poorer pain-related and psychosocial outcomes long-term.

CONCLUSIONS

Findings from the current scoping review and proposed conceptual framework will guide future research and treatment efforts for youths experiencing pain and trauma and/or PTSS and thereby enhance long-term outcomes.

Co-Occurring Trauma and Non-Suicidal Self-Injury Among People With Chronic Pain: A Systematic Review

PURPOSE OF REVIEW

Trauma and posttraumatic stress are common among individuals with chronic pain and contribute to increased morbidity and impairment. Individuals with trauma and chronic pain may be prone to non-suicidal self-injury, a relatively common yet risky self-regulatory behavior. There is a dearth of research on the intersection of trauma, chronic pain, and non-suicidal self-injury (NSSI). We conducted a systematic review of the extant literature.

RECENT FINDINGS

Five quantitative and eight case reports were identified. Only one quantitative study reported specifically on NSSI. Self-harm rates varied across studies, though appeared elevated among patients with chronic pain. Childhood trauma was linked to this co-occurrence. Causal links between trauma, NSSI, and pain are proposed, highlighting the need for a comprehensive theoretical model. We recommend assessing for childhood trauma when treating patients with chronic pain and querying regarding NSSI when patients present with indicators of NSSI risk and to treat or refer such patients to specialized treatment.

Emotional Processing and Its Association to Somatic Symptom Change in Emotional Awareness and Expression Therapy for Somatic Symptom Disorder: A Preliminary Mediation Investigation

Objective: The aim of this study was to investigate emotional processing as a potential mediator in therapist-guided, internet-based Emotional Awareness and Expression Therapy (I-EAET) for somatic symptom disorder, using data from a previously published pilot study.

Methods: Participants (N = 52) engaged in a 9-week I-EAET treatment. Before treatment and each week during treatment (i.e., 10 weekly measurements), emotional processing was assessed with the Emotional Processing Scale-25 (EPS-25), which contains five subscales, and somatic symptoms were assessed with the Patient Health Questionnaire-15 (PHQ-15).

Results: Mediation analyses using linear mixed models showed that two EPS-25 subscales—Signs of Unprocessed Emotions and Impoverished Emotional Experience—were uniquely associated with somatic symptom reduction. The proportion of the mediated effect was 0.49, indicating that about half of the total association of the PHQ-15 with symptoms was accounted for by the two EPS-25 subscales.

Conclusion: This preliminary mediation analysis suggests that improved emotional processing is associated with change in somatic symptoms in I-EAET. However, randomized controlled and comparison trials are needed to establish that I-EAET creates the change in emotional processing and that such changes are specific to I-EAET.

Classifying chronic pain using multidimensional pain-agnostic symptom assessments and clustering analysis

Chronic pain conditions present in various forms, yet all feature symptomatic impairments in physical, mental, and social domains. Rather than assessing symptoms as manifestations of illness, we used them to develop a chronic pain classification system. A cohort of real-world treatment-seeking patients completed a multidimensional patient-reported registry as part of a routine initial evaluation in a multidisciplinary academic pain clinic. We applied hierarchical clustering on a training subset of 11,448 patients using nine pain-agnostic symptoms. We then validated a three-cluster solution reflecting a graded scale of severity across all symptoms and eight independent pain-specific measures in additional subsets of 3817 and 1273 patients. Negative affect–related factors were key determinants of cluster assignment. The smallest subset included follow-up assessments that were predicted by baseline cluster assignment. Findings provide a cost-effective classification system that promises to improve clinical care and alleviate suffering by providing putative markers for personalized diagnosis and prognosis.

Psychophysiologic symptom relief therapy for chronic back pain: a pilot randomized controlled trial

INTRODUCTION

Chronic back pain is the leading cause of disability in the United States. Based on the hypothesis that nonspecific back pain may be rooted in a psychophysiologic etiology, we propose a new approach to chronic back pain.

OBJECTIVES

A pilot study was conducted to assess whether psychophysiologic symptom relief therapy (PSRT) can reduce disability and back pain bothersomeness for patients with chronic back pain.

METHODS

This was a three-armed, randomized trial for adults with nonspecific chronic back pain that compared PSRT with usual care and an active comparator (mindfulness-based stress reduction [MBSR]). Psychophysiologic symptom relief therapy-randomized participants received a 12-week (36 hours) course based on the psychophysiological model of pain. All groups were administered validated questionnaires at baseline and at 4, 8, 13, and 26 weeks. The primary outcome was the reduction in pain disability measured by the Roland-Morris Disability Questionnaire.

RESULTS

The mean Roland-Morris Disability Questionnaire score for the PSRT group (n = 11) decreased from 9.5 (±4.3 SDs) to 3.3 (±5.1) after 26 weeks which was statistically significant compared with both MBSR (n = 12) (P = 0.04) and usual care (n = 12) (P = 0.03). Pain bothersomeness scores and pain-related anxiety decreased significantly over 26 weeks in PSRT compared with MBSR and usual care (data in manuscript). At 26 weeks, 63.6% of the PSRT arm reported being pain free (0/10 pain) compared with 25.0% and 16.7% in MBSR and usual care arms, respectively. Psychophysiologic symptom relief therapy attendance was 76%, and there was 100% follow-up of all groups.

CONCLUSION

Psychophysiologic symptom relief therapy is a feasible and potentially highly beneficial treatment for patients with nonspecific back pain.

Mechanisms of change in depression and anxiety within a mind-body activity intervention for chronic pain

BACKGROUND

Chronic pain is challenging and costly to treat. Depression and anxiety co-occur with chronic pain. Identifying psychosocial mechanisms contributing to emotional outcomes among chronic pain patients can inform future iterations of this intervention.

METHODS

We examined explanatory mechanisms of change in emotional distress following a mind-body and activity intervention among 82 participants (21 - 79 years old, 65.85% female, 80.48% White). With depression and anxiety as outcomes, we hypothesized that potential mediators would include pain catastrophizing, mindfulness, and pain resilience. We used mixed-effects modeling to assess the indirect effects of time on each outcome variable through hypothesized mediators simultaneously.

RESULTS

Improvements in depression from baseline to post-treatment were most explained by pain catastrophizing (b = -2.53, CI = [-3.82, -1.43]), followed by mindfulness (b = -1.21, CI = [-2.15, -0.46]), and pain resilience (b = -0.76, CI = [-1.54, -1.66]). Improvements in anxiety from baseline to post-treatment were most explained by pain catastrophizing(b = -2.16, CI = [-3.45, -1.08]) and mindfulness (b = -1.51, CI = [-2.60, -0.65]), but not by pain resilience, (b = -0.47, CI = [-1.26, 0.17]).

LIMITATIONS

Findings are limited by the lack of a control group, relatively small sample, and two timepoints. However, findings can guide future mind-body intervention efficacy testing trials.

CONCLUSIONS

Pain catastrophizing and mindfulness appear to be important intervention targets to enhance emotional functioning for chronic pain patients, and should be considered simultaneously in interventions for chronic pain.

Wearable Respiratory Monitoring and Feedback for Chronic Pain in Adult Survivors of Childhood Cancer: A Feasibility Randomized Controlled Trial From the Childhood Cancer Survivor Study

PURPOSE

Approximately 40% of childhood cancer survivors experience chronic pain, with many also reporting pain-related disability. Given associations established in the general population among respiration, anxiety, and pain, continuous tracking and feedback of respiration may help survivors manage pain.

METHODS

A feasibility, nonblinded, randomized controlled trial (RCT) comparing wearable respiratory monitoring with a control group examined feasibility, acceptability, and preliminary efficacy among survivors of childhood cancer with chronic pain who were ≥ 18 years of age, able to speak and read English, lived in the United States, and had access to a smartphone and the Internet. The primary outcomes were pain interference, pain severity, anxiety, negative affect, and perceived stress. The intervention group (n = 32) received a wearable respiratory monitor, used the device, and completed an in-application breathing exercise daily for 30 days. The control group (n = 33) received psychoeducation after completion of the study.

RESULTS

Almost all participants in the intervention group (n = 31 of 32) and control group (n = 32 of 33) completed the study. Of those who completed the intervention, 90.3% wore the device for ≥ 50% of the trial. Posttreatment improvement for negative affect (Cohen d = 0.59; 95% CI, 0.09 to 1.10) was significantly greater in the intervention group compared with the control group. A follow-up study (n = 24) examined acceptability and feasibility of a second-generation device among those who completed the RCT. Most survivors (81.0%) wore the device daily during the trial and 85.7% reported satisfaction with the device and the application.

CONCLUSION

The results of this pilot study support the acceptability and feasibility of wearable respiratory monitoring among survivors of childhood cancer. Larger randomized trials are needed to assess efficacy and maintenance of this intervention for chronic pain.

Short-Term Psychodynamic Psychotherapy for Functional Somatic Disorders: A Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Functionalsomatic disorders (FSD) are common and costly, thereby driving the need for the development of effective brief treatment options. Short-term psychodynamic psychotherapy (STPP) is one candidate treatment method.

OBJECTIVE

To review and meta-analyze, where possible, randomized controlled trials (RCTs) of STPP for FSD.

METHODS

Following a systematic search of the literature, we performed a meta-analysis of available RCT groups to determine the effects of STPP on a range of outcomes after treatment, and medium- and long-term follow-ups.

RESULTS

In meta-analyses of 17 RCTs, STPP significantly outperformed minimal treatment, treatment as usual, or waiting list controls on somatic symptom measures at all time frames, with small to large magnitude effect sizes. Descriptive reviews of 5 RCTs suggest that STPP performed at least as well as other bona fide psychological therapies. Limitations of this meta-analysis include small samples of studies and possible publication bias.

CONCLUSIONS

STPP is a valid treatment option for diverse FSD conditions resulting in somatic symptom reductions that persist over time. STPP should be included in FSD treatment guidelines.

Short-term psychodynamic psychotherapy for functional somatic disorders: A systematic review and meta-analysis of within-treatment effects

OBJECTIVE

A recent meta-analysis of 17 randomized, controlled trials (RCTs) showed that Short-term Psychodynamic Psychotherapy (STPP) for functional somatic disorders (FSD) reduced somatic symptoms compared to wait list, minimal treatment, and treatment-as-usual controls. A clinically important yet unanswered question is how much improvement patients experience within STPP treatment.

METHODS

Following a systematic search, we identified STPP trials presenting data at baseline and post-treatment/follow-up. Meta-analyses determined the magnitude of changes in somatic symptoms and other outcomes from before to after STPP, and analyses examined effect sizes as a function of study, therapy, and patient variables.

RESULTS

We identified 37 trials (22 pre-post studies and 15 RCTs) totaling 2094 patients treated an average of 13.34 sessions for a range of FSD. Across all studies, somatic symptoms improved significantly from pre-treatment to short-term follow-up with a large effect size (SMD = -1.07), which was maintained at long-term follow-up (SMD = -0.90). After excluding two outlier studies, effects at short- and medium-term follow-up remained significant but were somewhat reduced in magnitude (e.g., short-term SMD = -0.73). Secondary outcomes including anxiety, depression, disability, and interpersonal problems had medium to large effects. Effects were larger for studies of STPP that were longer than 12 sessions or used an emotion-focused type of STPP, and for chronic pain or gastrointestinal conditions than for functional neurological disorders.

CONCLUSIONS

STPP results in moderate to large improvements in multiple outcome domains that are sustained in long-term follow-up. STPP is an effective treatment option for FSD and should be included in treatment guidelines.

Emotional awareness and other emotional processes: implications for the assessment and treatment of chronic pain

Emotional awareness (EA) is a key emotional process that is related to the presence and severity of chronic pain (CP). In this report, we describe primary and secondary emotions, discuss the distinction between emotional states and emotional regulation/processing, and summarize theory and research highlighting the significance of EA for CP. We describe ways to assess EA and diagnose centrally-mediated CP, for which emotional processes appear most relevant. We review several psychological interventions designed to enhance EA as well as several broader emotional processing treatments developed to address trauma and psychosocial conflicts underlying many patients' pain. We conclude by offering our perspective on how future integration of emotional processing into pain care could promote recovery from CP.

Internet-Administered Emotional Awareness and Expression Therapy for Somatic Symptom Disorder With Centralized Symptoms: A Preliminary Efficacy Trial

Background: There is growing evidence that trauma, psychosocial conflict, and difficulties with emotional processing contribute to centralized somatic symptoms. Emotional Awareness and Expression Therapy (EAET) was developed to address these factors and reduce symptoms, and EAET has shown efficacy in face-to-face formats. No trial of an internet-delivered EAET (I-EAET) exists, however, so we developed such an intervention and conducted an uncontrolled feasibility and potential efficacy trial of I-EAET for patients with Somatic Symptom Disorder (SSD) with centralized symptoms (SSD-CS). Method: After screening potential participants, a sample of 52 patients (50 women, two men; age M = 49.6, SD = 11.9) diagnosed with SSD-CS initiated treatment. I-EAET consisted of nine weekly modules focused on psychoeducation, emotional awareness and exposure, and anxiety regulation with self-compassion. Therapists communicated with each patient by email for about 20 min per week during treatment, answering questions and giving feedback on homework assignments. Patients completed measures of somatic symptoms, depression, anxiety, trauma-related symptoms, and functional disability before treatment and again at post-treatment and 4-month follow-up. Results: A large reduction in somatic symptoms (PHQ-15) occurred pre-to post-treatment (d = 1.13; 95% CI: 0.84-1.47) which was fully maintained at 4-month follow-up (d = 1.19; 95% CI: 0.88-1.56). Twenty-three percent of the patients at post-treatment and 27% at follow-up achieved a 50% or greater reduction in somatic symptoms, and about 70% achieved a minimally important clinical difference. In addition, at post-treatment, there were small to medium reductions (d's from 0.33 to 0.72) in anxiety (GAD-7), depression (PHQ-9), trauma-related symptoms (PCL-5), and functional disability (Sheehan Disability Scale). For all of these secondary outcomes, improvements were slightly to substantially larger at follow-up than at post-treatment (d's from 0.46 to 0.80). Conclusion: I-EAET appears to be a feasible treatment for adults with SSD and centralized symptoms, resulting in substantial and durable improvement not only in somatic symptoms but in other psychiatric symptoms and functioning. Controlled trials are needed determine the effects of I-EAET specifically and how this approach compares to face-to-face EAET and to other internet-delivered treatments, such as cognitive-behavioral interventions. Research should also identify treatment responders and mechanisms of change in EAET. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04122846.