Emotions and emotional approach and avoidance strategies in fibromyalgia

Alternative Treatments for Emotional Experiencing and Processing in People with Migraine or Tension-Type Headache: A Scoping Review

This narrative review aims to summarize the use of alternative treatments (e.g., relaxation training, meditation, written intervention) for emotional expression, processing, control, or management in patients with migraine and tension-type headaches, which the previous literature has shown to be related to migraine pain perception and headache symptoms. Online databases including PubMed, Scopus, Web of Science, PsycINFO, and Medline were searched to identify studies published between 2000 and 2023. A descriptive synthesis of the included studies was conducted. We included seven articles after screening 1.173 records. A total of 610 patients with a diagnosis of migraine or tension-type headache, and an average age of 19-45.5 years (68-90.4% females) were recruited in the selected studies. Overall, the results show that alternative approaches to headache treatment contribute to the management, reduction, or control of negative emotions and at the same time have a positive impact on pain perception and headache symptoms. However, in some cases, the effects are more promising than others, depending on the peculiarities or limitations of each approach considered. This review provides useful insights from a methodological point of view for future studies on the management or control of negative emotions in patients with migraine and tension-type headache.

Emotional experiences and gender roles of men with fibromyalgia syndrome: a cross-cultural qualitative study

Introduction

Gender roles may impact men with fibromyalgia, causing a high number of negative emotional states and affective disorders. There are few studies that detect men's high emotional suffering. This study examined the emotional experience of men with fibromyalgia.

Methods

A qualitative cross-cultural study utilized inductive thematic analysis was performed at the Fibromyalgia and Chronic Fatigue Unit Santa Maria University Hospital in Spain, the Fibromyalgia and Chronic Fatigue Clinic at Mayo Clinic in the US, and volunteers from the Winneshiek County in the US A total of 17 participants, 10 men from Spain and 7 men from the US were included.

Results

Three themes related to feelings/emotions emerged: (1) psychological level; (2) social level; and (3) physical level. Men with fibromyalgia from Spain and the US experienced many negative emotions. Men often experience negative emotions that are worsened by common misunderstandings and social biases/stigma about their condition.

Conclusion/implications

A proper assessment of emotions when evaluating the global health of men with fibromyalgia as well as the provision of emotional support would improve their mental health and therefore their overall physical health. Emotional management should be incorporated into all treatment protocols for fibromyalgia, especially for men given the gender stigma. Health policies designed by legislators, policymakers, and support agencies must be accompanied by education in gender role concepts to improve the emotions of men with FMS. The mass media will be essential for the disclosure of the emotional suffering of male patients so that society might better understand them.

Integrating intra- and interpersonal perspectives on chronic low back pain: the role of emotion regulation and attachment insecurity

Objective

Chronic low back pain (CLBP) is burdensome and interferes with psychological and physical functioning of those affected. Past research has examined interpersonal (e.g., attachment insecurity) or intrapersonal factors (e.g., emotion regulation [ER]) involved in chronic pain. However, to enhance our understanding of CLBP's biopsychosocial underpinnings, more empirical integration of both intra- and interpersonal factors involved in CLBP is needed. Thus, our study examined the independent and joint associations of insecure attachment dimensions and ER strategies with CLBP severity and interference.

Methods

We recruited 242 US adults with CLBP through Prolific Academic, an online participant pool. Participants from Prolific Academic were eligible for the study if they were at least 18 years of age, resided in the US, reported CLBP at least half the days over the past 6 months (>3 months), and used prescribed pain medication for their CLBP. Data collection was between November 2021 and February 2022. Eligible participants filled out a Qualtrics survey which consisted of measures assessing insecure attachment dimensions, ER strategies, as well as demographical information. Outcome variables in the present study were CLBP severity and interference. We ran multiple linear regression models to examine the associations between ER strategies and insecure attachment dimensions as predictors, and CLBP severity or interference as predicted variables, after controlling for sex as a covariate; we also conducted moderation analyses to investigate the interactions between ER strategies and insecure attachment dimensions when testing associations with CLBP severity or interference.

Results

Our results indicated that, after controlling for ER strategies, anxious attachment was positively associated with CLBP interference but not pain severity (CI: 0.101 to 0.569; CI: -0.149 to 0.186); avoidant attachment was not associated with CLBP interference or severity (CI: -0.047 to 0.511; CI: -0.143 to 0.256). After adjusting for anxious and avoidant attachment, emotional expression and expressive suppression were positively associated with CLBP severity (CI: 0.037 to 0.328; CI: 0.028 to 0.421) but not interference (CI: -0.003 to 0.403; CI: -0.406 to 0.143). Furthermore, emotional expression was associated with CLBP severity and interference at low and medium levels of avoidant attachment (CI: 0.165 to 0.682; CI: 0.098 to 0.455); expressive suppression and cognitive reappraisal did not interact with attachment dimensions when examining CLBP severity or interference (CIs: LLs ≤ -0.291 to ULs ≥ 0.030).

Conclusion

Our study shows that anxious attachment may be an interpersonal risk factor related to CLBP, above and beyond intrapersonal ERs, as anxious attachment was associated with higher levels of pain interference. Furthermore, emotional expression was associated with increased CLBP severity and interference, particularly among individuals at low and medium levels of avoidant attachment. Existing studies on chronic pain have mostly focused on examining intrapersonal or interpersonal correlates in isolation. The present study extends our understanding of CLBP by considering the role of interpersonal factors (i.e., insecure attachment dimensions), in combination with intrapersonal ER strategies. Given the correlational nature of the present study, longitudinal studies are needed to establish causality between psychosocial correlates and CLBP symptoms. Ultimately, we hope our integrated approach will facilitate the development of treatments and interventions tailored to address patients' attachment-related needs, enhancing the management and maintenance of CLBP among patients.

Measurement of event-related potentials from electroencephalography to evaluate emotional processing in Fibromyalgia Syndrome: A systematic review and meta-analysis

OBJECTIVE

The present systematic review and meta-analysis intended to: 1) determine the extent of abnormalities in emotional processing linked to emotional event-related potentials (ERPs) in Fibromyalgia Syndrome (FMS) and 2) integrate data from similar emotional tasks into a meta-analysis to clearly demonstrate the scientific and clinical value of measuring emotional ERPs by electroencephalography (EEG) in FMS.

METHODS

A systematic review and meta-analysis of studies comparing emotional processing indicated by ERPs in FMS patients and healthy controls was conducted. Fifteen articles were included in the systematic review after applying the eligibility criteria.

RESULTS

Nine articles demonstrated disturbances in emotional processing in FMS. These emotional disturbances were distributed over the whole range of ERP latencies, mainly over central, parietal, temporal and occipital areas. Despite of this, quantitative analysis revealed only significant differences in N250 and LPP/LPC between FMS patients and healthy controls, with smaller LPP/LPC and greater N250 seen in FMS.

DISCUSSION

N250 and LPP/LPC seem to be the ERPs with the greatest potential to determine emotional alterations in FMS. These ERPs are related to complex cognitive processes such as decoding features relevant to affect recognition (N250) as well differentiation between emotions, persistent engagement, conflict resolution or evaluation of emotional intensity (LPC/LPP). However, differences in task setup had an important impact on the variation of ERP outcomes. Systematization of protocols and tasks is indispensable for future studies.

Social cognition abilities in patients with primary and secondary chronic pain

Previous evidence suggested that chronic pain is characterized by cognitive deficits, particularly in the social cognition domain. Recently, a new chronic pain classification has been proposed distinguishing chronic primary pain (CPP), in which pain is the primary cause of patients' disease, and chronic secondary pain (CSP), in which pain is secondary to an underlying illness. The present study aimed at investigating social cognition profiles in the two disorders. We included 38 CPP, 43 CSP patients, and 41 healthy controls (HC). Social cognition was assessed with the Ekman-60 faces test (Ekman-60F) and the Story-Based Empathy Task (SET), whereas global cognitive functioning was measured with the Montreal Cognitive Assessment (MoCA). Pain and mood symptoms, coping strategies, and alexithymia were also evaluated. Correlations among clinical pain-related measures, cognitive performance, and psychopathological features were investigated. Results suggested that CSP patients were impaired compared to CPP and HC in social cognition abilities, while CPP and HC performance was not statistically different. Pain intensity and illness duration did not correlate with cognitive performance or psychopathological measures. These findings confirmed the presence of social cognition deficits in chronic pain patients, suggesting for the first time that such impairment mainly affects CSP patients, but not CPP. We also highlighted the importance of measuring global cognitive functioning when targeting chronic pain disorders. Future research should further investigate the cognitive and psychopathological profile of CPP and CSP patients to clarify whether present findings can be generalized as disorder characteristics.

Preference for Hedonic Goals in Fibromyalgia; Is It Always an Avoidance Mechanism? Looking the Relationship with Pain Acceptance from a Positive Psychology Perspective

The aim of this study was to analyze the effect of openness to experience on pain acceptance through positive affect (PA) considering the moderating role of preference for mood management goals in women with fibromyalgia (FM). A cross-sectional study (n = 231) was carried out. A simple mediation model and a moderate mediation model were conducted by SPSS macro-PROCESS. Results showed that PA mediated positively the effect of openness to experience on acceptance (B = 0.46, SE = 0.80, t = 5,59; 95% CI = [0.3016, 0.6298], p < .001) and that the contribution of openness to experience to PA varied at different values of mood management goals (medium: - .04; ß = .40, p < .001; high: .95; ß = .61, p<.001). Findings may serve as a foundation for tailored interventions to promote activity through acceptance focusing on PA and mood management goals among women with medium to high level of hedonic goals.

Abnormal functional neurocircuitry underpinning emotional processing in fibromyalgia

Fibromyalgia, a condition characterized by chronic pain, is frequently accompanied by emotional disturbances. Here we aimed to study brain activation and functional connectivity (FC) during processing of emotional stimuli in fibromyalgia. Thirty female patients with fibromyalgia and 31 female healthy controls (HC) were included. Psychometric tests were administered to measure alexithymia, affective state, and severity of depressive and anxiety symptoms. Next, participants performed an emotion processing and regulation task during functional magnetic resonance imaging (fMRI). We performed a 2 × 2 ANCOVA to analyze main effects and interactions of the stimuli valence (positive or negative) and group (fibromyalgia or HC) on brain activation. Generalized psychophysiological interaction analysis was used to assess task-dependent FC of brain regions previously associated with emotion processing and fibromyalgia (i.e., hippocampus, amygdala, anterior insula, and pregenual anterior cingulate cortex [pACC]). The left superior lateral occipital cortex showed more activation in fibromyalgia during emotion processing than in HC, irrespective of valence. Moreover, we found an interaction effect (valence x group) in the FC between the left pACC and the precentral and postcentral cortex, and central operculum, and premotor cortex. These results suggest abnormal brain activation and connectivity underlying emotion processing in fibromyalgia, which could help explain the high prevalence of psychopathological symptoms in this condition.

Emotional Dynamics in Fibromyalgia: Pain, Fatigue, and Stress Moderate Momentary Associations Between Positive and Negative Emotions

Affective disruptions, particularly deficits in positive affect, are characteristic of fibromyalgia (FM). The Dynamic Model of Affect provides some explanations of affective disruptions in FM, suggesting that the inverse association between positive and negative emotions is stronger when individuals with FM are under greater stress than usual. However, our understanding of the types of stressors and negative emotions that contribute to these affective dynamics is limited. Using ecological momentary assessment (EMA) methods, 50 adults who met the FM survey diagnostic criteria rated their momentary pain, stress, fatigue, negative emotions (depression, anger, and anxiety), and positive emotions 5X/day for eight days using a smartphone application. Results of multilevel modeling indicate that, consistent with the Dynamic Model of Affect, there was a stronger inverse association between positive emotion and negative emotions during times of greater pain, stress, and fatigue. Importantly, this pattern was specific to depression and anger, and was not present for anxiety. These findings suggest that fluctuations in fatigue and stress may be just as important or more important than fluctuations in pain when understanding the emotional dynamics in FM. In addition, having a more nuanced understanding of the role that different negative emotions play may be similarly important to understanding emotional dynamics in FM. PERSPECTIVE: This article presents new findings on the emotional dynamics in FM during times of increased pain, fatigue, and stress. Findings highlight the need for clinicians to conduct a comprehensive evaluation of fatigue, stress, and anger in addition to more routinely assessed depression and pain when working with individuals with FM.

Feasibility, Acceptability, and Preliminary Efficacy of a Positive Affect Skills Intervention for Adults With Fibromyalgia

Background and Objectives

To examine the feasibility, acceptability, and preliminary efficacy of a positive affect skills intervention for middle-aged and older adults with fibromyalgia syndrome (FMS).

Research Design and Methods

Ninety-five participants with FMS aged 50 and older (94% female) were randomized to 1 of 2 conditions: (a) Lessons in Affect Regulation to Keep Stress and Pain UndeR control (LARKSPUR; n = 49) or (b) emotion reporting/control (n = 46). LARKSPUR included 5 weeks of skill training that targeted 8 skills to help foster positive affect, including (a) noticing positive events, (b) savoring positive events, (c) identifying personal strengths, (d) behavioral activation to set and work toward attainable goals, (e) mindfulness, (f) positive reappraisal, (g) gratitude, and (h) acts of kindness. Outcome data were collected via online surveys at baseline, postintervention, and 1-month follow-up.

Results

Completion rates (88%) and satisfaction ratings (10-point scale) were high (LARKSPUR: M = 9.14, standard deviation (SD) = 1.49; control: M = 8.59, SD = 1.97). Improvements were greater in LARKSPUR participants compared with control participants on measures of positive affect (Cohen's d = 0.19 [0.15, 0.24]), negative affect (Cohen's d = -0.07 [-0.11, -0.02]), and pain catastrophizing (Cohen's d = -0.14 [-0.23, -0.05]). Improvements in positive affect (Cohen's d = 0.17 [0.13, 0.22]) and negative affect (Cohen's d = -0.11 [-0.15, -0.06]) were maintained at 1-month follow-up. Dose-response analyses indicated that intervention engagement significantly predicted pre-to-post and post-to-follow-up reductions in pain catastrophizing.

Discussion and Implications

The current preliminary findings add to existing literature and highlight the specific potential of internet-delivered positive affect skills programs for adults with FMS.

Clinical Trial Registration

NCT04869345.

Neurophysiological and Psychosocial Mechanisms of Fibromyalgia: A Comprehensive Review and Call for An Integrative Model

Research into the neurobiological and psychosocial mechanisms involved in fibromyalgia has progressed remarkably in recent years. Despite this, current accounts of fibromyalgia fail to capture the complex, dynamic, and mutual crosstalk between neurophysiological and psychosocial domains. We conducted a comprehensive review of the existing literature in order to: a) synthesize current knowledge on fibromyalgia; b) explore and highlight multi-level links and pathways between different systems; and c) build bridges connecting disparate perspectives. An extensive panel of international experts in neurophysiological and psychosocial aspects of fibromyalgia discussed the collected evidence and progressively refined and conceptualized its interpretation. This work constitutes an essential step towards the development of a model capable of integrating the main factors implicated in fibromyalgia into a single, unified construct which appears indispensable to foster the understanding, assessment, and intervention for fibromyalgia.

Psychoeducation for Fibromyalgia Syndrome: A Systematic Review of Emotional, Clinical and Functional Related-Outcomes

Fibromyalgia Syndrome (FMS) is a chronic condition of widespread pain accompanied by several symptoms such as stiffness, fatigue, sleep problems, depression, anxiety, and cognitive deficits. To date, there is no specific treatment for FMS. The European League Against Rheumatism, and the majority of the international recommendations for managing FMS, has claimed psychoeducational intervention as the first step in FMS treatment for adequate symptoms management. However, scientific studies in this regard are scarce, diverse, and with contradictory findings. Results integration from analogous studies could provide a clear presentation of the real clinical value of psychoeducation in FMS. Therefore, the current systematic review aims at exploring the effect of psychoeducation on emotional, clinical, and functional symptoms of FMS patients and encourages researchers towards psychoeducation's procedure optimization and systematization. The systematic review was conducted according to the guidelines of the Cochrane Collaboration and PRISMA statements. The selected articles were evaluated using the Cochrane risk of bias (ROB) assessment tool. The selected articles were extracted from PubMed, Scopus, and Web of Science databases. The literature search identified 11 studies eligible for the systematic review. The ROB evaluation revealed that 2 of the 11 studies showed a low quality, the other 2 had a moderate quality, and the remaining 7 studies exhibited a high quality. Results showed that psychoeducation is generally included as an important first therapeutic step in multicomponent treatments for FMS. Moreover, psychoeducation generally seems to be quite beneficial in reducing emotional (i.e., number of days feeling emotionally well, general anxiety, depression levels, etc.) and clinical symptoms (levels of fatigue, morning stiffness, pain intensity, etc.), as well as increasing functional status (i.e., general physical function, morning fatigue, stiffness, etc.). Despite that psychoeducation´s clinical benefits are highlighted, there is scarce amount of research on psychoeducation beyond its usefulness as part of multicomponent treatments.

Why Does It Hurt So Much? Emotion Regulation Mediates the Association between Fibromyalgia Symptoms and Psychological Distress

While it is known that fibromyalgia patients often suffer from depression and stress symptoms, there is inconclusive evidence as to why these symptoms occur. The aim of this study is to examine the role of emotion regulation in mental health symptoms among treatment-seeking individuals with fibromyalgia. Ninety-three (93) participants (mean age = 47.25, SD = 12.4) were recruited from one of Israel's largest community healthcare providers. They were administered self-report questionnaires assessing fibromyalgia (FIQR), perceived stress (PSS), major depression (PHQ-9), and difficulties in emotion regulation (DERS). Associations were found between measures of fibromyalgia symptoms, psychological distress, and emotion regulation. Several sub-indices of emotion regulation showed significant correlations with psychological distress, with non-acceptance of emotional responses showing the strongest associations. Moreover, non-acceptance of emotion responses mediated the association between fibromyalgia symptoms and psychological distress. Our findings show that the connection between fibromyalgia symptoms and psychological distress is partially explained by difficulties in emotion regulation. Moreover, we show that specific emotion regulation strategies play a differential role in fibromyalgia patients' distress, thereby highlighting the importance of identifying unique psychotherapeutic targets. Specifically, regulating emotions through acceptance of emotional responses seems to be particularly important for fibromyalgia patients, as they cope with stigma and a lack of validation.

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.

The relationship of alexithymia to pain and other symptoms in fibromyalgia: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

People with fibromyalgia (FM) often report having difficulty with emotional identification and expression, and this "alexithymia" may contribute to their pain and other symptoms. Multiple studies have assessed alexithymia in FM, and we systematically reviewed and meta-analyzed this literature to: (a) describe the prevalence of alexithymia in people with FM; (b) compare the level of alexithymia in FM to both healthy controls and controls with other pain conditions; and (c) determine the association of alexithymia to pain intensity, depression, and anxiety in people with FM.

DATABASES AND DATA TREATMENT

Following PRISMA guidelines, we searched multiple databases (Scopus, PubMed/MEDLINE, Embase, Web of Science, PsycINFO and Google Scholar) from inception to May 31, 2022. Study quality was assessed with The Joanna Briggs Institute (JBI) tools for cross-sectional studies, and STATA:17 was used for meta-analysis. A total of 32 studies met eligibility criteria and were included in meta-analyses.

RESULTS

The prevalence of alexithymia in FM averaged 48%. People with FM had substantially higher alexithymia than healthy controls (SMD = 1.00; 95% CI: 0.79 to 1.22), as well people with other pain-related conditions (SMD = 0.35, 95% CI = 0.04 to 0.65), particularly rheumatoid arthritis (SMD = 0.49; 95% CI: 0.08-0.91). Alexithymia was positively associated with pain intensity (r = 0.24), anxiety (r = 0.50), and depression (r = 0.41) among people with FM.

CONCLUSIONS

Due to the high level of alexithymia in people with FM and the positive relationship of alexithymia with pain and psychological distress, interventions to improve emotional awareness, expression, and processing in FM are recommended.

Emotion regulation and the salience network: a hypothetical integrative model of fibromyalgia

Fibromyalgia is characterized by widespread pain, fatigue, sleep disturbances and other symptoms, and has a substantial socioeconomic impact. Current biomedical and psychosocial treatments are unsatisfactory for many patients, and treatment progress has been hindered by the lack of a clear understanding of the pathogenesis of fibromyalgia. We present here a model of fibromyalgia that integrates current psychosocial and neurophysiological observations. We propose that an imbalance in emotion regulation, reflected by an overactive 'threat' system and underactive 'soothing' system, might keep the 'salience network' (also known as the midcingulo-insular network) in continuous alert mode, and this hyperactivation, in conjunction with other mechanisms, contributes to fibromyalgia. This proposed integrative model, which we term the Fibromyalgia: Imbalance of Threat and Soothing Systems (FITSS) model, should be viewed as a working hypothesis with limited supporting evidence available. We hope, however, that this model will shed new light on existing psychosocial and biological observations, and inspire future research to address the many gaps in our knowledge about fibromyalgia, ultimately stimulating the development of novel therapeutic interventions.

When It Hurts, a Positive Attitude May Help. The Moderating Effect of Positive Affect on the Relationship Between Walking, Depression, and Symptoms in Women with Fibromyalgia

BACKGROUND

Increased exercise is a marker of health in fibromyalgia (FM). However, patients frequently avoid physical activity as a way of minimizing the pain they feel. This deprives them of opportunities to obtain positive reinforcement, increasing functional impact.

AIMS

This study examines the mediating role of depressive symptoms between walking (as physical exercise), functional impact, and pain, at different levels of positive affect (PA) among women with fibromyalgia.

DESIGN

Cross-sectional correlational study.

SETTINGS

Mutual aid associations for fibromyalgia in Spain.

PARTICIPANTS

231 women diagnosed with FM.

METHODS

Moderate mediation analyses were conducted using PROCESS.

RESULTS

First, a simple mediation model showed that depression mediated the effect of walking on functional impact, but not on pain. Additionally, the moderated mediated model showed that this effect was significant at medium and high levels of PA, but not when levels of PA were low.

CONCLUSIONS

Provision of resources focused on positive affect seem to increase the positive effects of walking on functional impact through the reduction of depressive symptoms. Nurses can improve adherence of patients with FM to walking behavior through increasing positive affect.

A behavioral and brain imaging dataset with focus on emotion regulation of women with fibromyalgia

Fibromyalgia is a chronic condition characterized by widespread pain, as well as numerous symptoms related to central sensitization such as: fatigue, cognitive disturbances, constipation/diarrhea and sensory hypersensitivity. Furthermore, depression and anxiety are prevalent comorbidities, accompanied by emotion processing and regulation difficulties. Although fibromyalgia physiopathology is still not fully understood, neuroimaging research methods have shown brain structural and functional alterations as well as neuroinflammation abnormalities. We believe that open access to data may help fibromyalgia research advance more. Here, we present an open dataset of 33 fibromyalgia female patients and 33 paired healthy controls recruited from a Mexican population. Dataset includes demographic, clinical, behavioural and magnetic resonance imaging (MRI) data. The MRI data consists of: structural (T1- and T2- weighted) and functional (task-based and resting state) sequences. The task was an emotion processing and regulation task based on visual stimuli. The MRI data contained in the repository are unprocessed, presented in Brain Imaging Data Structure (BIDS) format and available on the OpenNeuro platform for future analysis.

Measurement(s)	Blood Oxygen Level-Dependent Functional MRI • brain • Emotion
Technology Type(s)	functional magnetic resonance imaging • Magnetic Resonance Imaging • Emotion regulation task
Factor Type(s)	valence • emotion regulation condition
Sample Characteristic - Organism	Homo sapiens
Sample Characteristic - Environment	laboratory environment
Sample Characteristic - Location	Mexico

The Mediating Role of Depression and Pain Catastrophizing in the Relationship between Functional Capacity and Pain Intensity in Patients with Fibromyalgia

Background

Fibromyalgia syndrome (FMS) is a chronic musculoskeletal pain condition characterized by widespread pain, sleep problems (i.e., insomnia and unrefreshing sleep), fatigue, cognitive, and emotional difficulties. Although pain has been proposed the factor mostly impacting in the FMS patients' function, emotional and psychological FMS-associated factors are also known to exert a negative impact in quality of life and functional capacity. Nonetheless, the relationship between these factors and functional limitations in FMS patients is considered to be complex and not clearly defined. Therefore, the present study is aimed at assessing the associations between FMS functional capacity, FMS symptoms (pain, fatigue, insomnia, depression, and state and trait anxiety), and associated psychological factors such as pain catastrophizing, as well as the possible mediating role of these latter in the relationship between pain and FMS functional capacity.

Method

115 women diagnoses with FMS completed a set of self-administered questionnaires to evaluate the clinical and psychological variables of the study.

Results

FMS functional capacity was positively associated with the majority of FMS symptoms except state anxiety. Regression analyses confirmed a greater prediction for FMS functional capacity by depression, fatigue, and pain catastrophizing, in this sequence. Both, pain catastrophizing and depression were important factors mediating the association between clinical pain (total and intensity) and FMS functional capacity.

Conclusions

Findings support a key role of pain catastrophizing and depression in the disability associated to pain in FMS. Treatment goals directed to lessen depression and pain catastrophizing levels should be promoted to reduce the impact of pain in FMS patients' daily function.

The Influence of Adverse Childhood Experiences in Pain Management: Mechanisms, Processes, and Trauma-Informed Care

Adverse childhood experiences (ACEs) increase the likelihood of reduced physical and psychological health in adulthood. Though understanding and psychological management of traumatic experiences is growing, the empirical exploration of ACEs and physical clinical outcomes remains under-represented and under-explored. This topical review aimed to highlight the role of ACEs in the experience of chronic pain, pain management services and clinical decision making by: (1) providing an overview of the relationship between ACEs and chronic pain; (2) identifying biopsychosocial mechanisms through which ACEs may increase risk of persistent pain; (3) highlighting the impact of ACEs on patient adherence and completion of pain management treatment; and (4) providing practical clinical implications for pain management. Review findings demonstrated that in chronic pain, ACEs are associated with increased pain complications, pain catastrophizing and depression and the combination of these factors further heightens the risk of early treatment attrition. The pervasive detrimental impacts of the COVID-19 pandemic on ACEs and their cyclical effects on pain are discussed in the context of psychological decline during long treatment waitlists. The review highlights how people with pain can be further supported in pain services by maintaining trauma-informed practices and acknowledging the impact of ACEs on chronic pain and detrimental health outcomes. Clinicians who are ACE-informed have the potential to minimize the negative influence of ACEs on treatment outcomes, ultimately optimizing the impact of pain management services.

The Longitudinal Relationship Between Emotion Regulation and Pain-Related Outcomes: Results From a Large, Online Prospective Study

People with chronic pain engage in various strategies, such as pain catastrophizing and pain acceptance, to regulate the difficult emotional aspects of living with pain. Engagement in these strategies is known to influence pain severity and pain interference. However, less research has examined the extent to which general emotion regulation, the ability to identify emotions and engage in strategies to alter emotions, relates to pain-related outcomes. The current study, a large (N = 1453) online prospective study of adults with chronic pain, employed theory-driven assessment of emotion regulation to determine the extent to which general difficulties with emotion regulation at baseline relate to pain severity and pain interference at three-month follow-up, above and beyond pain catastrophizing and pain acceptance. We conducted a series of path models, controlling for demographic covariates and baseline pain severity and pain interference. Pain catastrophizing and pain acceptance at baseline significantly predicted pain interference at three-month follow-up. However, when indices of general emotion regulation were entered into the model, the associations between pain catastrophizing and pain interference (B = .009, P = .153) were no longer statistically significant. Alexithymia emerged as a significant predictor of pain severity (B = .012, P = .032) and pain interference (B = .026, P < .001). These findings highlight the value of considering the role of general emotion regulation (particularly identifying and describing emotions), in addition to pain-specific experiences, in understanding risk for poor pain-related outcomes. PERSPECTIVE: In addition to pain catastrophizing and pain acceptance, difficulties regulating emotions in general (particularly elevated alexithymia) relates to pain outcomes three months later. These findings shed light on risk for poor pain outcomes and point to general emotion regulation as a potentially important target of chronic pain intervention.

Central nervous activity during an emotional Stroop task in fibromyalgia syndrome

Fibromyalgia syndrome (FMS) is a chronic condition of widespread pain accompanied by symptoms like depression, fatigue and cognitive impairments. In addition to central nervous pain sensitization, emotional dysregulation may be involved in FMS pathogenesis. This study investigated emotional influences on cognitive processing in FMS. Event-related potentials and theta oscillations were recorded during an emotional Stroop task including positive, negative, and neutral adjectives in 36 FMS patients and 35 controls. Patients had larger P3 amplitudes and greater theta power than controls, independent of the emotional word content. In patients, but not controls, negative words were associated with a larger late positive component (LPC) amplitude than positive words. No group difference was seen for P1, early posterior negativity or N4. Reaction times (RTs) were longer in patients than controls, independent of emotional word content. The P3 and theta oscillation findings suggest greater cognitive effort and attentional mobilization in FMS, which is needed to overcome the reduction of attentional resources resulting from central nervous pain sensitization. Although RTs do not support attentional bias in FMS, emotional modulation of the LPC amplitude may reflect preferential central nervous processing of negative information, which could contribute to pain and affective symptoms characterizing FMS. ACCESS TO RESEARCH DATA: The research data of the study are available to the public via the Open Science Framework repository (OSF: https://osf.io/tsyre/).

Whole-Body Cryostimulation in Fibromyalgia: A Scoping Review

Currently, all available therapies for the control and management of fibromyalgia (FM) are mostly focused on relieving patients’ symptoms and improving their quality of life. The purpose of this review is to provide an up-to-date overview of the evidence supporting the beneficial effects of whole-body cryostimulation (WBC) in patients with FM and evidence-based guidance on the possible adjuvant use of WBC in the treatment of FM. We searched the most recent literature by retrieving 10 eligible studies, 4 of which were abstracts only, from a total of 263 records. Thermal stress caused by cryostimulation induces an analgesic effect, improving pain, redox balance, and inflammatory symptoms in an exercise-mimicking fashion. In addition, it reduces the feeling of fatigue, improves mood, and reduces mental health deterioration with positive consequences on depressive states and improved sleep quality. Although the studies included in this review are not of sufficient quality and quantity to draw definitive conclusions about the effectiveness of WBC in FM, initial evidence indicates WBC as a promising add-on option in the multidisciplinary treatment of FM, due to its rapid action and high patients’ compliance. The application of WBC protocols has the potential to expand therapeutic options for the treatment of FM and related disorders; however, larger, high-quality primary studies are still needed.

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.

Longitudinal associations of physical fitness and affect with depression, anxiety and life satisfaction in adult women with fibromyalgia

PURPOSE

This study analysed the longitudinal associations of physical fitness and affect with depression, anxiety and life satisfaction at 2- and 5-year follow-up.

METHODS

In 312 adult women with fibromyalgia, physical fitness was measured by performance-based tests and affect, depression, anxiety and life satisfaction were self-reported using the Positive and Negative Affect Schedule (PANAS), Beck Depression Inventory-second edition (BDI-II), State Trait Anxiety Inventory-I (STAI) and Satisfaction with Life Scale (SWLS), respectively. We conducted sequential linear regression analyses adjusted for baseline levels of depression, anxiety, life satisfaction, age, body fat percentage and education.

RESULTS

At the 2-year follow-up, all the associations under study were significant. At the 5-year follow-up, a number of associations remained significant. First, lowering negative affect was independently associated with lower depression, anxiety and higher life satisfaction (β's from 0.14 to 0.31). Second, favourable changes in positive affect were independently associated with lower anxiety (β = 0.21) and higher life satisfaction (β = 0.28). Third, enhancing physical fitness was related to higher life satisfaction (β = 0.16).

CONCLUSION

Reductions in negative affect were associated with more favourable depression, anxiety and life satisfaction at the 2- and 5-year follow-up. Improvements in positive affect were associated with more favourable anxiety and life satisfaction and enhancements in physical fitness were associated with higher life satisfaction. If corroborated in clinical-experimental research, these findings may guide the development of interventions that are tailored to the levels of physical fitness, affect and the outcome of interest (i.e. depression, anxiety or life satisfaction) in women with fibromyalgia.

Exploring the Preference for Fatigue-avoidance Goals as a Mediator Between Pain Catastrophizing, Functional Impairment, and Walking Behavior in Women With Fibromyalgia

OBJECTIVES

Along with the symptoms of pain and fatigue, pain catastrophizing and avoidance behaviors are highly prevalent and associated with functional impairment in fibromyalgia (FM) patients. Although pain and fatigue affect patients' quality of life, research has been exclusively focused on how pain affects physical activity and exercise. The aim of this study was to analyze the role of pain catastrophizing and preference for fatigue-avoidance goals in walking behavior and functional impairment in women with FM.

MATERIALS AND METHODS

In this cross-sectional study the sample was composed of 76 participants aged 18 years and older (mean age=55.05, SD=7.70). The study evaluated pain catastrophizing, preference for fatigue-avoidance goals, functional impairment, and walking behavior along with sociodemographic variables and clinical data.

RESULTS

Pain catastrophizing was associated with preference for fatigue-avoidance goals and this preference was associated with greater functional impairment and less distance walked. Path analysis supported the mediating role of preference for fatigue-avoidance goals in the relationship between pain catastrophizing and walking behavior and between pain catastrophizing and functional impairment. Furthermore, pain catastrophizing predicted greater preference for fatigue-avoidance goals which predicted more problems in functioning and less distance walked.

DISCUSSION

The present study may help clarify the connection between the factors that stop individuals with FM from implementing beneficial behaviors such as walking, and thus, allowing for the design of psychological interventions that seek to maintain physical functioning despite experiencing fatigue.

Fibromyalgia: Evidence for Deficits in Positive Psychology Resources. A Case-Control Study from the Al-Ándalus Project

Positive psychology is the study of positive subjective experience and individual traits. Identifying deficits in positive psychology regarding fibromyalgia may inform targets for management. Therefore, the aim of the present case–control study was to compare the levels of positive affect, negative affect, satisfaction with life, optimism and emotional repair in a large sample of women with fibromyalgia (cases) and age-matched peers without fibromyalgia (controls). This case–control study included 437 women with fibromyalgia (51.6 ± 7.1 years old) and 206 age-matched women without fibromyalgia (50.6 ± 7.2 years old). Participants self-reported their levels of (i) subjective well-being on the Positive and Negative Affect Schedule and the Satisfaction with Life Scale, (ii) dispositional optimism on the Life Orientation Test-Revised and (iii) emotional repair on the Trait Meta-Mood Scale. Women with fibromyalgia showed lower levels of positive affect, satisfaction with life, optimism and emotional repair and higher levels of negative affect. Large effect sizes were found for positive affect, negative affect and satisfaction with life (all, Cohen’s d ≥ 0.80) and small-to-moderate for emotional repair and optimism (both, Cohen’s d ≥ 0.50). Women with fibromyalgia experience deficits of positive psychology resources. Thus, developing tailored therapies for fibromyalgia focusing on reducing deficits in positive psychology resources may be of clinical interest, though this remains to be corroborated in future research.

Facial Emotion Recognition and Executive Functions in Fibromyalgia

OBJECTIVE

The ability to accurately identify facial expressions of emotions is crucial in human interaction. Although a previous study suggested deficient emotional face recognition in patients with fibromyalgia, not much is known about the origin of this impairment. Against this background, the present study investigated the role of executive functions. Executive functions refer to cognitive control mechanisms enabling implementation and coordination of basic mental operations. Deficits in this domain are prevalent in fibromyalgia.

METHODS

Fifty-two fibromyalgia patients and thirty-two healthy individuals completed the Ekman-60 Faces Test, which requires classification of facial displays of happiness, sadness, anger, fear, surprise, and disgust. They also completed eight tasks assessing the executive function components of shifting, updating, and inhibition. Effects of comorbid depression and anxiety disorders, as well as medication use, were tested in stratified analyses of patient subgroups.

RESULTS

Patients made more errors overall than controls in classifying the emotional expressions. Moreover, their recognition accuracy correlated positively with performance on most of the executive function tasks. Emotion recognition did not vary as a function of comorbid psychiatric disorders or medication use.

CONCLUSIONS

The study supports impaired facial emotion recognition in fibromyalgia, which may contribute to the interaction problems and poor social functioning characterizing this condition. Facial emotion recognition is regarded as a complex process, which may be particularly reliant on efficient coordination of various basic operations by executive functions. As such, the correlations between cognitive task performance and recognition accuracy suggest that deficits in higher cognitive functions underlie impaired emotional communication in fibromyalgia.

Contextualizing goal preferences in fear-avoidance models. Looking at fatigue as a disabling symptom in fibromyalgia patients

The fear-avoidance model provides an explanation for the development of chronic pain, including the role of perception (i.e. pain catastrophism) as an explanatory variable. Recent research has shown that the relationship between pain catastrophism and avoidance is influenced in turn by different psychological and contextual variables, highlighting the affective-motivational ones. From this perspective, the Goal Pursuit Questionnaire (GPQ) was developed to measure the preference for hedonic goals (mood-management or pain-avoidance goals) over achievement goals in musculoskeletal pain patients. Recently, the Spanish version of the GPQ in fibromyalgia patients has been validated. Our aim has been to adapt the Spanish version of GPQ from pain to fatigue symptoms and to validate this new questionnaire (GPQ-F) in fibromyalgia. Despite the recognition of fibromyalgia as a complex disorder and the need for a differential study of its symptoms, fatigue, despite its high prevalence and limiting nature, remains the forgotten symptom. We conducted a cross-sectional study with 231 women with fibromyalgia. Previously, we adapted the Spanish GPQ for fatigue symptoms with three sub-studies (group structured interview, self-administration questionnaire and thinking-aloud; n = 15–27 patients). We explored the GPQ structure and performed path analyses to test conditional mediation relationships. Exploratory factor analysis showed two factors: ‘Fatigue-avoidance goal’ and ‘Mood-management goal’ (39.3% and 13.9% of explained variance, respectively). The activity avoidance pattern fully mediated the relation between both catastrophizing and fatigue-avoidance goals with fatigue. The study shows initial findings about the usefulness of the GPQ-F as a tool to analyze goal preferences related to fatigue in fibromyalgia. The results supported the mediational role of activity avoidance patterns in the relationship between preference for fatigue-avoidance goals and fatigue.

Interoceptive Sensibility, Alexithymia, and Emotion Regulation in Individuals Suffering from Fibromyalgia

INTRODUCTION

People suffering from fibromyalgia syndrome report various difficulties in emotional processing, possibly resulting from changes in bodily perception (interoception). In our study, we investigated the relationships between interoceptive sensibility (IS) and two disease-relevant emotional components (alexithymia and emotion regulation) in fibromyalgia sufferers compared to healthy individuals.

METHODS

Fifty-five fibromyalgia sufferers and 55 healthy individuals, matched with regard to age and gender, participated in our cross-sectional study. All participants completed the following self-report measures: the Multidimensional Assessment of Interoceptive Awareness, the Toronto Alexithymia Scale, and the Emotion Regulation Skills Questionnaire. Depression and anxiety scores served as confounding variables.

RESULTS

Fibromyalgia sufferers reported a stronger tendency to note as well as to avoid (unpleasant) body sensations. IS and psychopathology each explained about thirty percent of the variance in emotion regulation in fibromyalgia sufferers. Alexithymia was related to IS and emotion regulation in controls but not in fibromyalgia sufferers.

CONCLUSION

Disturbances in interoception could be seen as the starting point of emotional difficulties in people with fibromyalgia. Following the fear-avoidance-model, experiential avoidance may restrict patients' ability to adaptively regulate emotional states, possibly initiating a vicious cycle of psychological distress and pain.

Behavioral, Physiological and EEG Activities Associated with Conditioned Fear as Sensors for Fear and Anxiety

Anxiety disorders impose substantial costs upon public health and productivity in the USA and worldwide. At present, these conditions are quantified by self-report questionnaires that only apply to behaviors that are accessible to consciousness, or by the timing of responses to fear- and anxiety-related words that are indirect since they do not produce fear, e.g., Dot Probe Test and emotional Stroop. We now review the conditioned responses (CRs) to fear produced by a neutral stimulus (conditioned stimulus CS+) when it cues a painful laser unconditioned stimulus (US). These CRs include autonomic (Skin Conductance Response) and ratings of the CS+ unpleasantness, ability to command attention, and the recognition of the association of CS+ with US (expectancy). These CRs are directly related to fear, and some measure behaviors that are minimally accessible to consciousness e.g., economic scales. Fear-related CRs include non-phase-locked phase changes in oscillatory EEG power defined by frequency and time post-stimulus over baseline, and changes in phase-locked visual and laser evoked responses both of which include late potentials reflecting attention or expectancy, like the P300, or contingent negative variation. Increases (ERS) and decreases (ERD) in oscillatory power post-stimulus may be generalizable given their consistency across healthy subjects. ERS and ERD are related to the ratings above as well as to anxious personalities and clinical anxiety and can resolve activity over short time intervals like those for some moods and emotions. These results could be incorporated into an objective instrumented test that measures EEG and CRs of autonomic activity and psychological ratings related to conditioned fear, some of which are subliminal. As in the case of instrumented tests of vigilance, these results could be useful for the direct, objective measurement of multiple aspects of the risk, diagnosis, and monitoring of therapies for anxiety disorders and anxious personalities.

Lower Fatigue in Fit and Positive Women with Fibromyalgia: The al-Ándalus Project

OBJECTIVE

To analyze 1) the independent association of physical fitness, positive affect, and negative affect with the different dimensions of fatigue (general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue) and 2) whether the interactions of physical fitness, positive affect, and negative affect were associated with fatigue over and above the independent association.

DESIGN

Cross-sectional study in 420 women with fibromyalgia.

SETTING

Fibromyalgia associations from southern Spain.

METHODS

Physical fitness was measured by performance-based tests, and questionnaires were used to measure positive affect, negative affect, and different dimensions of fatigue (general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue). Age, body mass index, and current pain level were included as potential confounders in all analyses.

RESULTS

Physical fitness was independently associated with general fatigue, physical fatigue, and reduced activity (all P ≤ 0.02). Positive affect was independently associated with all fatigue dimensions (all P < 0.001). Negative affect was independently associated with general fatigue, physical fatigue, reduced motivation, and mental fatigue (all P ≤ 0.04). The interaction of overall physical fitness and positive affect was related to general fatigue and physical fatigue (all P ≤ 0.02). Women with fibromyalgia with higher levels of overall physical fitness and positive affect showed the lowest general fatigue and physical fatigue.

CONCLUSIONS

In women with fibromyalgia, positive affect was independently and consistently associated with all dimensions of fatigue. The combination of higher levels of overall physical fitness and positive affect might serve as a buffer against general and physical fatigue in women with fibromyalgia.

Emotional affection on a sustained attention task: The importance the aging process and depression

Chronic pain is a complex experience that has now become a major public health issue. This has prompted many researchers to study attention, understanding it to be a crucial factor that allows altering the experience of pain, while attributing considerable importance to sustained attention. Accordingly, the main studies in this field stress the importance of emotion regulation processes and emotions on the perception of painful stimuli and attentional processes themselves. Nevertheless, only a handful of studies have been found that directly study the relationship between these variables. Within this context, this article sets out to analyse emotional regulation processes, emotional variables (depression and anxiety), the experience of pain, and age on the ability to maintain the vigilance response in a sample of patients with chronic pain. This involved selecting a sample of 49 patients with rheumatoid arthritis and examining their performance in an ad-hoc sustained attention test. With a view to complying with the study's main purpose, the participants were also assessed through the use of the following self-report measures: the Beck Depression Inventory (BDI-I); the Hospital Anxiety and Depression Scale (HADS); the McGill Pain Questionnaire, and the Difficulties in Emotion Regulation Scale (DERS). Linear regression analyses revealed a significant impact of the aging process on the performance times in the attention task. Likewise, age and depression recorded a significant correlation with the mistakes made during the task. These results suggest that higher depression levels and an older age might be related to a worse adaptation to pain management techniques based on attention processes, such as mindfulness.

Diagnostic Criteria for Fibromyalgia: Critical Review and Future Perspectives

Fibromyalgia syndrome (FMS) is a chronic illness characterized by widespread pain and other clinical and emotional symptoms. The lack of objective markers of the illness has been a persistent problem in FMS research, clinical management, and social recognition of the disease. A critical historical revision of diagnostic criteria for FMS, especially those formulated by the American College of Rheumatology (ACR), was performed. This narrative review has been structured as follows: Introduction; historical background of FMS, including studies proposing and revising the diagnostic criteria; the process of development of the ACR FMS diagnostic criteria (1990 and 2010 versions); revisions of the 2010 ACR FMS diagnostic criteria; the development of scales based on the 2010 and 2011 criteria, which could help with diagnosis and evaluation of the clinical severity of the disease, such as the Polysymptomatic Distress Scale and the FMS Survey Questionnaire; relationships of prevalence and sex ratio with the different diagnostic criteria; validity and diagnostic accuracy of the ACR FMS criteria; the issues of differential diagnosis and comorbidity; the strength and main limitations of the ACR FMS criteria; new perspectives regarding FMS diagnosis; and the impact of the novel findings in the diagnosis of FMS. It is concluded that despite the official 2010 FMS diagnostic criteria and the diagnostic proposal of 2011 and 2016, complaints from health professionals and patients continue.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

Alexithymia in individuals with chronic pain and its relation to pain intensity, physical interference, depression, and anxiety: a systematic review and meta-analysis

Numerous studies have examined how alexithymia (difficulty identifying and describing one's emotions and a preference for externally oriented thinking) relates to chronic pain and associated disability. We conducted a systematic review and meta-analysis to summarize individual studies that either assessed alexithymia in individuals with chronic pain vs controls or related alexithymia to pain intensity, physical interference, depression, and anxiety. We searched MEDLINE, Embase, and PsycINFO from inception through June 2017; 77 studies met the criteria (valid assessment of alexithymia in adults or children with any chronic pain condition) and were included in analyses (n = 8019 individuals with chronic pain). Primary analyses indicated that chronic pain samples had significantly higher mean alexithymia scores compared with nonclinical (d = 0.81) and clinical nonpain (d = 0.55) controls. In chronic pain samples, alexithymia was significantly positively associated with pain intensity (d = 0.20), physical interference (d = 0.17), depression (d = 0.46), and anxiety (d = 0.43). Secondary meta-analyses of 14 studies that conducted partial correlations that controlled for negative affect-related measures revealed that alexithymia was no longer significantly related to pain intensity or interference. Meta-analysis findings demonstrated that alexithymia is elevated in individuals with chronic pain and related to greater pain intensity and physical interference, although the latter relationships may be accounted for by negative affect. Critical future work is needed that examines alexithymia assessed using non-self-report measures, develops a person-centered perspective on this construct, and identifies how alexithymia is relevant to the assessment and treatment of individuals with chronic pain.

Need for Affect, Interpersonal Psychological Theory of Suicide, and Suicide Proneness

The present study expands upon the Interpersonal Psychological Theory of Suicide (IPTS), examining its relationship with the need for affect (NFA), a construct explaining attitudes toward seeking both positive and negative emotions. A sample of 576 emerging adults completed measures of NFA, IPTS, suicide proneness, and demographics online. Findings include NFA accounting for a small significant amount of suicide proneness, a positive association between approaching emotions and one indicator of suicide proneness, negative association between approaching emotions and thwarted belongingness, and positive associations between avoidance of emotions with both perceived burdensomeness and thwarted belongingness. Findings are discussed concerning NFA as a theoretically and practically relevant factor for understanding suicide.

Goal Preferences, Affect, Activity Patterns and Health Outcomes in Women With Fibromyalgia

Some motivational models understand health behavior as a result of the interaction between goal preferences and mood. However, this perspective has not been explored in fibromyalgia. Furthermore, in chronic pain, it has only been explored with regard to negative affect. Thus, our aims were: (1) to develop a Spanish version of the Goal Pursuit Questionnaire (GPQ); (2) to explore the relationships between goal preferences and health outcomes, testing the moderator role of affect and the mediating role of chronic pain activity patterns. We conducted two cross-sectional studies. In Study 1, after a double translation/back-translation process, we interviewed 94 women attending the Fibromyalgia Unit of the Community of Valencia in order to identify the cultural feasibility and the content validity of the GPQ. Study 2 comprised 260 women. We explored the GPQ structure and performed path analyses to test conditional mediation relationships. Eight activities from the original GPQ were changed while maintaining the conceptual equivalence. Exploratory factor analysis showed two factors: 'Pain-avoidance goal' and 'Mood-management goal' (37 and 13% of explained variance, respectively). These factors refer to patients' preference for hedonic goals (pain avoidance or mood-management) over achievement goals. Robust RMSEA fit index of the final models ranged from 0.039 for pain to 0.000 for disability and fibromyalgia impact. Pain avoidance goals and negative affect influenced pain mediated by task-contingent persistence. They also affected disability mediated by task and excessive persistence. Pain avoidance goals and positive affect influenced fibromyalgia impact mediated by activity avoidance. We also found a direct effect of negative and positive affect on health outcomes. Preference for pain avoidance goals was always related to pain, disability and fibromyalgia impact through activity patterns. Affect did not moderate these relationships and showed direct and indirect paths on health outcomes, mainly by increasing persistence and showing positive affect as an asset and not a risk factor. Intervention targets should include flexible reinforcement of achievement goals relative to pain avoidance goals and positive affect in order to promote task-persistence adaptive activity patterns and decreased activity avoidance.

Anger rumination mediates differences between fibromyalgia patients and healthy controls on mental health and quality of life

The present study examined differences between fibromyalgia patients and healthy controls on anger rumination, mental health and quality of life and tested anger rumination as a mediator of patient-control differences in mental health and quality of life. Participants were a propensity score-matched sample of 58 fibromyalgia patients and 58 healthy controls. Participants completed measures of anger rumination, depression and anxiety and quality of life. Patients were higher than controls on all anger rumination scales and depression and anxiety and lower on quality of life. All anger rumination scales were related to poorer mental health and quality of life. Patient-control differences on mental health and quality of life were mediated by anger rumination. In multiple mediator models, the only subscale with unique mediating effects was anger memories. Anger rumination has potent associations with mental health and quality of life, and differences between patients and controls on mental health and quality of life are partially mediated by differences in anger rumination. Addressing tendencies to ruminate on anger experiences in the care of fibromyalgia patients may offer an important avenue to improved health and quality of life. © 2019 John Wiley & Sons, Ltd.

Emotion regulation in patients with somatic symptom and related disorders: A systematic review

Background

Somatic symptoms and related disorders (SSD) are prevalent phenomena in the health-care system. Disturbances in emotion regulation (ER) are commonly observed in patients suffering from SSD.

Objectives

This review aimed to examine ER processes that characterize SSD by a systematic analysis of the available empirical studies.

Data sources

PsycINFO and PubMed databases for the articles published between January 1985 and June 2018.

Search terms

“emotion/al regulation” or “affect regulation” and various forms of SSD.

Study eligibility criteria

Empirical studies that a) assigned adolescent or adult patients suffering from SSD based on a clinical diagnosis, and b) examined the relationship between ER and SSD, were included.

Study synthesis methods

A tabular summary of the articles was generated according to study characteristics, study quality, variables, and findings. The findings were organized based on ER variables used in the articles and diagnoses of SSD, which were then re-organized under the main constituents of ER (attention, body, and knowledge).

Results

The findings of the 64 articles largely supported the association between SSD and disturbances in ER, which are usually shared by different diagnoses of SSD. The results indicate that patients show a reduced engagement with cognitive content of emotions. On the other hand, bodily constituents of ER seem to depict an over-reactive pattern. Similarly, the patients tend to encounter difficulties in flexibly disengaging their (spontaneous) attention from emotional material.

Limitations

There is a scarcity of longitudinal designs, randomized controlled trials, experiments, and diary studies suited to investigate the short- and long-term causal relationship between ER and SSD. Symptoms of SSD and measures to assess emotion regulation are heterogeneous.

Conclusions and implications

Assessment of ER processes is potentially useful to understand SSD and for treatment planning. Furthermore, a concurrent investigation of the dynamic interaction of the ER modalities promises insights for better understanding of the role of ER in development, course, and maintenance of SSD.

Fibromyalgia patients make scarce reference to pain in self-defining memories

OBJECTIVE

Self-defining memories (SDMs) are vivid, emotionally intense and well-rehearsed autobiographical memories that provide fundamental information about one's cognitive affective motivational representation of self. Exploring SDMs in fibromyalgia (FM) is of interest for understanding the psychopathology of this disorder and improving clinical interventions. Our aim was to compare patients and healthy controls (HC) on SDM characteristics.

METHOD

We included 25 patients with FM and 24 HC matched for age, sex and education level. Each participant described five SDMs, which were coded for content, specificity, integration, tension, redemption, contamination, affective response, date, and reference to pain. We statistically controlled our results for the most plausible confounding factors related to FM that could affect SDM recall, namely depression, anxiety, cognitive inhibition, pain severity and medication.

RESULTS

Compared with HC, patients retrieved less specific SDMs with a more negative emotional valence but less tension. They reported more relationship-related memories, and fewer redemptive ones, with less meaning-making. The number of memories referring to physical or psychological pain did not differ between groups. None of the confounding factors we analysed could explain (either alone or in combination) the statistical differences between groups for SDMs characteristics.

CONCLUSION

We discuss functional avoidance and alexithymia as two main factors for poor reference to pain in patients' SDMs that further reveal affective dysregulation in FM. In clinical practice, remediating the way in which pain is integrated into SDMs in FM may help to mitigate its negative impact on everyday life.

BEEP-Bodily and Emotional Perception of Pain. A Questionnaire to Measure Reaction to Pain in Chronic Pain Disorders

Background: The assessment of pain and its impact on quality of life is central to the evaluation of chronic pain syndromes. However, most available tools focus on the nociceptive experience of pain, and at best only consider the occurrence of anxious, depressive, or cognitive problems. Here is a new questionnaire aimed at measuring the multifaceted impact of pain in chronic pain syndromes, the Bodily and Emotional pErception of Pain (BEEP).

Methods: All consecutive patients who accessed a center for the treatment of pain were invited to take part in the study. The sample included 222 participants (51 with fibromyalgia, 84 with low back pain; 87 with other chronic pain syndromes). Women were 77% of the sample, the mean age was 61 ± 15. Participants completed the BEEP, the Patient Health Questionnaire-9 (PHQ-9), and the Mood Disorder Questionnaire (MDQ).

Results: Reliability was good for all questionnaires. The expected three dimensions of the BEEP were confirmed by confirmatory factor analysis, and a bifactor model with three orthogonal factors showed a good fit as well. Participants diagnosed with fibromyalgia showed higher scores on the BEEP than the participants who had been diagnosed with low back pain or other chronic pain syndromes. The prevalence of probable cases of major depression and bipolar disorder in the sample was higher than expected for non-clinical samples. Levels of depression, as measured by the PHQ-9, were associated with the three dimensions of the BEEP and with the intensity of pain.

Conclusions: The BEEP is a promising measure of the impact of pain in daily life and differentiates fibromyalgia from other chronic pain syndromes. The BEEP may be helpful to evaluate the patient's response to the treatment over time and may favor the identification of unmet needs in patients' personal, social, and daily functioning.

Psychological impact of fibromyalgia: current perspectives

Fibromyalgia syndrome (FMS) is a chronic disorder characterized by widespread and persistent musculoskeletal pain and other frequent symptoms such as fatigue, insomnia, morning stiffness, cognitive impairment, depression, and anxiety. FMS is also accompanied by different comorbidities like irritable bowel syndrome and chronic fatigue syndrome. Although some factors like negative events, stressful environments, or physical/emotional traumas may act as predisposing conditions, the etiology of FMS remains unknown. There is evidence of a high prevalence of psychiatric comorbidities in FMS (especially depression, anxiety, borderline personality, obsessive-compulsive personality, and post-traumatic stress disorder), which are associated with a worse clinical profile. There is also evidence of high levels of negative affect, neuroticism, perfectionism, stress, anger, and alexithymia in FMS patients. High harm avoidance together with high self-transcendence, low cooperativeness, and low self-directedness have been reported as temperament and character features in FMS patients, respectively. Additionally, FMS patients tend to have a negative self-image and body image perception, as well as low self-esteem and perceived self-efficacy. FMS reduces functioning in physical, psychological, and social spheres, and also has a negative impact on cognitive performance, personal relationships (including sexuality and parenting), work, and activities of daily life. In some cases, FMS patients show suicidal ideation, suicide attempts, and consummated suicide. FMS patients perceive the illness as a stigmatized and invisible disorder, and this negative perception hinders their ability to adapt to the disease. Psychological interventions may constitute a beneficial complement to pharmacological treatments in order to improve clinical symptoms and reduce the impact of FMS on health-related quality of life.

Ego Depletion as a Measure of Emotion Processing Deficits among MUS Patients

Previous studies have found a link between emotion processing deficits and medically unexplained physical symptoms (MUS). The majority of previous studies have used self-report measures of emotional processing, with the majority focusing on alexithymia, and have produced inconsistent and contradictory results. In the present study, we investigated the role of emotion-processing deficits in MUS by assessing emotion regulation performance and the effects of performance on ego depletion. Participants with high or low levels of self-reported MUS watched emotion-evoking videos under instructions to allow or suppress their emotional reactions, and then performed an anagram task to measure their effort and perseverance. Contrary to the research with self-report measures, experimental analysis of emotion-processing revealed that MUS is correlated with the inability to regulate negative emotions. Unexpected self-regulatory tendencies of the participants with high symptom levels were discussed.

Pain Expressions and Inhibitory Control in Patients With Fibromyalgia: Behavioral and Neural Correlates

Fibromyalgia (FM) is a generalized chronic pain condition associated with a variety of symptoms, including altered cognitive and emotional processing. It has been proposed that FM patients show a preferential allocation of attention to information related to the symptoms of the disease, particularly to pain cues. However, the existing literature does not provide conclusive evidence on the presence of this attentional bias, and its effect on cognitive functions such as inhibitory control. To clarify this issue, we recorded the electroencephalographic activity of 31 women diagnosed with FM and 28 healthy women, while performing an emotional Go/NoGo task with micro-videos of pain, happy, and neutral facial expressions. We analyzed behavioral data, performed EEG time-frequency analyses, and obtained the event-related potentials (ERPs) N2 and P3 components in NoGo trials. A series of self-reports was also administered to evaluate catastrophic thinking and the main symptoms of fibromyalgia. Pain expressions were associated with longer reaction times and more errors, as well as with higher theta and delta power, and P3 amplitude to NoGo stimuli. Thus, behavioral and psychophysiological data suggest that increased attention to pain expressions impairs the performance of an inhibitory task, although this effect was similar in FM patients and healthy controls. N2 amplitude was modulated by type of facial expression (larger to pain faces), but only for the control group. This finding suggests that the presentation of pain faces might represent a smaller conflict for the patients, more used to encounter pain stimuli. No main group effects were found significant for N2 or P3 amplitudes, nor for time-frequency data. Using stimuli with greater ecological validity than in previous studies, we could not confirm a greater effect of attentional bias toward negative stimuli over inhibitory performance in patients with FM. Studying these effects allow us to better understand the mechanisms that maintain pain and develop intervention strategies to modify them.

Emotional awareness and expression therapy, cognitive behavioral therapy, and education for fibromyalgia: a cluster-randomized controlled trial

Patients with fibromyalgia (FM) experience increased lifetime levels of psychosocial adversity, trauma, and emotional conflict. To address these risk factors, we developed emotion awareness and expression therapy (EAET) and tested its benefits against an active control condition, FM education, and the field's gold standard intervention for FM, cognitive behavioral therapy (CBT) for symptom management. Adults with FM (N = 230) formed 40 treatment groups, which were randomized to EAET, CBT, or education and given 8, 90-minute sessions. Patient-reported outcomes were assessed at baseline, posttreatment, and 6-month follow-up (primary end point). Retention of patients to follow-up was excellent (90.4%). Intent-to-treat analyses indicated that although EAET did not differ from FM education on pain severity (primary outcome), EAET had significantly better outcomes than FM education on overall symptoms, widespread pain, physical functioning, cognitive dysfunction, anxiety, depression, positive affect, and life satisfaction (between-condition d's ranging from 0.29-0.45 SD) and the percentage of patients reporting being "very much/much" improved (34.8% vs 15.4%). Emotional awareness and expression therapy did not differ from CBT on the primary or most secondary outcomes, but compared to CBT, EAET led to significantly lower FM symptoms (d = 0.35) and widespread pain (d = 0.37) and a higher percentage of patients achieving 50% pain reduction (22.5% vs 8.3%). In summary, an intervention targeting emotional awareness and expression related to psychosocial adversity and conflict was well received, more effective than a basic educational intervention, and had some advantages over CBT on pain. We conclude that EAET should be considered as an additional treatment option for FM.

Effects of a community-based multicomponent rehabilitation programme for patients with fibromyalgia: protocol for a randomised controlled trial

INTRODUCTION

People with fibromyalgia (FM) suffer from symptoms such as widespread pain, non-refreshing sleep, fatigue and reduced quality of life. Effects of pharmacological treatment are questionable and non-pharmacological treatments are recommended as first-line therapy. To date the majority of patients with FM in Norway are not offered any targeted treatment. The aim of this randomised controlled trial is to investigate the effects of a community-based multicomponent rehabilitation programme comprising an acceptance-based and mindfulness-based group intervention, the Vitality Training Programme (VTP), followed by tailored physical activity counselling.

MATERIALS AND METHODS

General practitioners refer potential participants to a rheumatologist in specialist healthcare for diagnostic clarification and assessment of comorbidities. Inclusion criteria are widespread pain/FM ≥3 months, age 20-50 and work participation (minimum part-time) within the last 2 years. The intervention group attends the VTP comprising 10 weekly 4 hour group sessions plus a booster session after 6 months. Thereafter, they receive 12 weeks of individually tailored physical exercise counselled by physiotherapists at community-based Healthy Life Centers. The control group follows treatment as usual. The primary outcome is Patient Global Impression of Change. Secondary outcomes include self-reported pain, fatigue and sleep quality, psychological distress, mindfulness, health-related quality of life, physical activity, work ability and exercise beliefs and habits. To achieve a power of 80% and allow for 10% dropout, 70 participants are needed in each arm. All analyses will be conducted on intention-to-treat bases and measured as differences between groups at 12 months follow-up.

ETHICS AND DISSEMINATION

The study is approved and granted by the Norwegian South-Eastern Regional Health Authority (reference 2016015). Ethics approval was obtained from Regional Committee for Medical and Health Research Ethics (reference 2015/2447/REK sør-øst A). Results will be submitted to appropriate journals and presented in relevant conferences and social media.

TRIAL REGISTRATION

ISRCTN 96836577.

The role of emotion regulation in chronic pain: A systematic literature review

OBJECTIVE

Emotion regulation (ER) includes a set of cognitive and attentional processes used to change or maintain emotional state. A small but growing body of research suggests that maladaptive ER might be a risk factor for the development of chronic pain. This review aims to summarize existing literature on the association between ER and chronic pain, and to determine whether the construct of ER may further enhance our understanding of the risk and protective factors that may contribute to the onset and maintenance of chronic pain.

METHODS

A systematic search was conducted using the search terms "chronic pain" and "emotion regulation." Studies that measured both constructs across all age groups were included.

RESULTS

We found 15 studies that met our inclusion criteria. Nine studies were completed within the last five years, suggesting that the evaluation of ER as it relates to pain is a new line of research. Studies that measured "response-focused" ER found associations between maladaptive ER and pain. Studies that measured "antecedent-focused" ER strategies were less likely to show a direct association with pain.

CONCLUSION

Maladaptive response-focused ER may be an important risk factor in the development and maintenance of chronic pain, as it is associated with pain and psychological comorbidities. Adding ER to chronic pain investigations may help to further explain individual differences in the risk and protective mechanisms that are known to influence chronic pain. Importantly, this line of research has potential to directly inform future interventions for patients with chronic pain.