Jay L. Cohen

Pain and emotion: a biopsychosocial review of recent research.

OBJECTIVE AND METHOD Research on emotion and pain has burgeoned. We review the last decades literature, focusing on links between emotional processes and persistent pain. RESULTS Neurobiological research documents the neural processes that distinguish affective from sensory pain dimensions, link emotion and pain, and generate central nervous system pain sensitization. Psychological research demonstrates that greater pain is related to emotional stress and limited emotional awareness, expression, and processing. Social research shows the potential importance of emotional communication, empathy, attachment, and rejection. CONCLUSIONS Emotions are integral to the conceptualization, assessment, and treatment of persistent pain. Research should clarify when to eliminate or attenuate negative emotions, and when to access, experience, and express them. Theory and practice should integrate emotion into cognitive-behavioral models of persistent pain.

Pain, Executive Functioning, and Affect in Patients with Rheumatoid Arthritis

ObjectivesRheumatoid arthritis (RA) is a chronic inflammatory disease resulting in substantial pain. The physical and emotional effects of RA are well known, but little attention has been given to the potential cognitive effects of RA pain, although intact executive functioning in patients with chronic illness is crucial for the successful completion of many daily activities. We examined the relationship between pain and executive functioning in patients with RA, and also considered the influence of positive and negative affect in the relationship between pain and executive functioning. MethodsA sample of 157 adults with RA completed measures of pain and positive and negative affect and were tested for working memory and selective attention using the Letter Number Sequencing subtest from the Wechsler Adult Intelligence Scale—Third Edition and the Stroop Color Word Test tests, respectively. ResultsConsistent with prior research, pain was inversely related to executive functioning, with higher pain levels associated with poorer performance on executive functioning tasks. This relationship was not moderated or mediated by negative affect; however, positive affect moderated the relationship between pain and executive functioning. For patients high in positive affect there was a significant inverse relationship between pain and executive functioning, whereas there was no such relationship for patients low in positive affect. DiscussionThese findings are discussed in the context of cognitive research on the effects of positive affect on executive functioning and functional neuroanatomical research suggesting neurocognitive mechanisms for such moderation.

AN EMOTIONAL EXPOSURE-BASED TREATMENT OF TRAUMATIC STRESS FOR PEOPLE WITH CHRONIC PAIN: PRELIMINARY RESULTS FOR FIBROMYALGIA SYNDROME

Emotional trauma occurs in many patients with chronic pain, particularly fibromyalgia syndrome (FMS). Current cognitive-behavioral treatments for chronic pain have limited effects, perhaps because the trauma is not addressed, whereas emotional exposure-based treatments improve post-traumatic stress, but have not been tested on chronic pain. We present a novel, brief treatment protocol for people with chronic pain and unresolved trauma (Multi-Stimulus, Multi-Technique Emotional Exposure Therapy), which involves detecting avoidance of a range of emotion-related stimuli, implementing exposure techniques tailored to the patients avoidances, and negotiating the process and therapeutic alliance. This treatment was pilot tested on 10 women with intractable FMS and trauma histories. Three months post-treatment, the sample showed moderate to large effects on stress symptoms, FMS impact, and emotional distress; and small to moderate improvements on pain and disability. Two patients showed substantial improvement, four made moderate gains, two showed modest improvement, and two did not benefit. This pilot study suggests that emotional exposure treatment for unresolved trauma may benefit some patients with FMS. Controlled testing of the treatment for FMS and other chronic pain populations is indicated.

Does Emotional Disclosure About Stress Improve Health in Rheumatoid Arthritis? Randomized, Controlled Trials of Written and Spoken Disclosure

&NA; Studies of the effects of disclosing stressful experiences among patients with rheumatoid arthritis (RA) have yielded inconsistent findings, perhaps due to different disclosure methods – writing or speaking – and various methodological limitations. We randomized adults with RA to a writing (n = 88) or speaking (to a recorder) sample (n = 93), and within each sample, to either disclosure or 1 of 2 control groups (positive or neutral events), which conducted four 20‐minute, at‐home sessions. Follow‐up evaluations at 1, 3, and 6 months included self‐reported, behavioral, physiological, and blinded physician‐assessed outcomes. In both writing and speaking samples, the disclosure and control groups were comparably credible, and the linguistic content differed as expected. Covariance analyses at each follow‐up point indicated that written disclosure had minimal effects compared with combined controls – only pain was reduced at 1 and 6 months, but no other outcomes improved. Spoken disclosure led to faster walking speed at 3 months, and reduced pain, swollen joints, and physician‐rated disease activity at 6 months, but there were no effects on other outcomes. Latent growth curve modeling examined differences in the trajectory of change over follow‐up. Written disclosure improved affective pain and walking speed; spoken disclosure showed only a marginal benefit on sensory pain. In both analyses, the few benefits of disclosure occurred relative to both positive and neutral control groups. We conclude that both written and spoken disclosure have modest benefits for patients with RA, particularly at 6 months, but these effects are limited in scope and consistency. Both written and spoken methods of emotional disclosure have some health benefits for patients with rheumatoid arthritis, but the effects are limited.

The effects of different methods of emotional disclosure: differentiating post‐traumatic growth from stress symptoms

Research on emotional disclosure should test the effects of different disclosure methods and whether symptoms are affected differently than post-traumatic growth. We randomized 214 participants with unresolved stressful experiences to four disclosure conditions (written, private spoken, talking to a passive listener, talking to an active facilitator) or two control conditions. All groups had one 30-minute session. After 6 weeks, disclosure groups reported more post-traumatic growth than controls, and disclosure conditions were similar in this effect. All groups decreased in stress symptoms (intrusions, avoidance, psychological and physical symptoms), but disclosure did not differ from control. We conclude that 30 minutes of disclosure leads to post-traumatic growth but not necessarily symptom reduction, and various disclosure methods have similar effects. Research on the effects of disclosure should focus on the benefits of growth as well as symptom reduction.

Perceived support and relational effects in psychotherapy process constructs.

Recent research has indicated that only a small portion of supportiveness reflects the objective properties of providers. Instead, supportiveness primarily reflects the unique relationships among specific recipients and providers (i.e., relational effects), thus suggesting new approaches to support interventions. The authors investigated the possibility that similar relational effects occur for therapy process constructs (e.g., working alliance). Isolating relational effects in psychotherapy requires that each client receive treatment from more than one therapist during the same period of time. Therefore, we conducted analog studies in which therapy clients and students viewed videos of therapists and then rated expected therapist supportiveness and expected therapy process constructs for each therapist. Two studies indicated very strong relational effects in therapist supportiveness and therapy process constructs. In addition, process constructs were correlated strongly with supportiveness (Study 1) and favorable affect (Study 2) for relational effects specifically. Implications for integrating research on perceived support and therapy process were discussed.

The effects of written emotional disclosure and coping skills training in rheumatoid arthritis: A randomized clinical trial

OBJECTIVE Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing. METHOD We randomized 264 adults with RA in a 2 × 2 factorial design to 1 of 2 writing conditions (WED vs. control writing) followed by 1 of 2 training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups. RESULTS Completion of each intervention was high (>90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and analyses of covariance at each assessment point, revealed no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared with control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: Compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on 1 of 2 measures at 4 and 12 months. CONCLUSIONS The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.

Different methods of single-session disclosure: what works for whom?

OBJECTIVE Examine distress, emotional approach coping, and attachment as moderators of effects of written (WED) versus interpersonal (IED) emotional disclosure and written time management (WTM). DESIGN/METHODS Fifty-seven undergraduates with stressful experiences randomized to a single session of WED, IED, or WTM. Assessment of immediate reaction (NA) and 6-week follow-up (intrusions/avoidance). RESULTS Those with higher baseline distress had increased NA, avoidance and intrusions when engaged in WED or IED (vs. WTM). For emotional processors, WED (vs. IED) produced less NA, avoidance, and intrusions. Attachment predicted increased NA in WTM. CONCLUSIONS Baseline distress and personality characteristics form boundary conditions for written disclosure.

What is the Right Thing to Say? Agreement among Perceivers on the Supportiveness of Statements

Abstract Most social support theory implies that there are objectively supportive people and statements. Yet there is little agreement among perceivers that some people are more supportive than others. Nonetheless, there might be better agreement regarding supportive statements. In three studies, children, college students, and members of a clinical training program rated the supportiveness of specific statements presented by text or video. Agreement among perceivers accounted for only 11% of the variance (range = 8%–12%). Perceivers disagreed because of their traitlike perceptual biases, as well as perceivers’ idiosyncratic tastes. Implications for social support theory were discussed.

Poster 255: Comparison of Treatment Outcomes in Patients not on Opioids and those Weaned from Opioids During a Functional Restoration Program: A Case Series

men and women (62.6% vs 58.6%; P .33) and of opioidnaive and opioid-experienced patients (63.1% vs 57.2%; P .15). However, in the opioid-experienced subgroup, patients who received oxycodone previously were significantly less likely to complete titration than those who had received hydrocodone (45.6% vs 61.5%; P .03). Conclusions: The majority of patients with moderate to severe CLBP were successfully titrated to a twice-daily oxymorphone ER dose that provided effective, generally welltolerated analgesia. Seniors and patients switching from oxycodone may require more careful titration to optimize success.