Emotional Processing

and Regulation in

Chronic Pain Sufferers

Dr Jorge E. Esteves, PhD, MA, BSc, DO

j.esteves@bso.ac.uk

Outline

• Neuroanatomy of pain and emotion

• Investigating the relationship between

various chronic pain states and emotional

processing

• Implications for osteopathic practice and

further research

Pain

Why did it happen to me?

What is its purpose?

My experiences?

How?

What is it?

…

Pain and emotion

• Nociception normally results in pain; however,

pain may be experienced without nociception.

• Negative emotions are a constituent of the pain

experience, so a close relationship between brain

processes related to pain and emotions is

expected.

• Arguably, pain is an emotion which requires the

presence of a bodily sensation with qualities like

those reported in a tissue-damaging conditions

(Price, 1999)

Price, D. D. (1999). Psychological mechanisms of pain and analgesia. Seattle,

WA: IASP Press.

Pain, emotion and survival

• Pain and emotion share common adaptive

responses to survival-relevant environmental

challenges to ensure survival.

• Pain’s main functional significance is to alert the

organism that its body integrity is threatened, to

attend to the source of pain and possibly avoid it.

• Emotion’s functional significance lies in the

detection of motivationally relevant stimuli that

may trigger avoidance or approach behaviour.

Wieser, M.J, and Pauli, P. (2016). Neuroscience of Pain and Emotion. In M.A.

Flaten and M. al'Absi (Eds). Neuroscience of Pain, Stress, and Emotion:

Psychological and Clinical Implications (pp. 3-27). Academic Press Inc:

Elsevier

Pain…• Includes both sensory (nociception) and affective

(emotional unpleasantness) dimensions;

• Pain usually engages the emotional systems,

both in the short-term and the long-term;

• Emotional feelings regarding the long-term

consequences of pain, termed secondary affect,

contribute to the psychosocial aspects of pain

management.

Central processing of pain• Parallel pathways for nociception

• First order neurons are ganglion cells with peripheral processes that

terminate as free nerve endings – including Aδ mechanosensitive

nociceptors; respond to intense or damaging mechanical stimuli; Aδ

mechanothermal nociceptors; and C polymodal nociceptors

• There are distinct qualities of pain that are conveyed via parallel

central pathways that originate with these different classes of first

order neurons - first (sharp) pain - Aδ and second pain - C

polymodal nociceptors

• Affective dimensions of pain - nociceptive signals reach ‘limbic’

structures in the forebrain, including the anterior cingulate gyrus,

insular cortex, amygdala and orbital-medial prefrontal cortex.

Anterolateral system for pain processing

Brain network for acute pain

Wieser, M.J, and Pauli, P. (2016). Neuroscience of Pain and Emotion. In M.A.

Flaten and M. al'Absi (Eds). Neuroscience of Pain, Stress, and Emotion:

Psychological and Clinical Implications (pp. 3-27). Academic Press Inc:

Elsevier

Emotions…

• There are two taxonomies of emotions:

• Categorical classes – six evolutionary shaped

basic emotions such as joy, fear, anger,

sadness, disgust and surprise

• Dimensions of valence (positive or negative

response to stimuli; pleasant or unpleasant)

and arousal (high or low)

Wieser, M.J, and Pauli, P. (2016). Neuroscience of Pain and Emotion. In M.A.

Flaten and M. al'Absi (Eds). Neuroscience of Pain, Stress, and Emotion:

Psychological and Clinical Implications (pp. 3-27). Academic Press Inc:

Elsevier

Emotional networks in the brain• Research examining brain activations related to the

elicited valence and arousal (pictures) show that:

• Negatively valenced stimuli trigger activations in the amygdala,

hippocampus, and medial occipital lobe, and especially right

amygdala and left caudate body activity increased with the arousal

qualities of unpleasant pictures.

• Positively valenced pictures triggered activations in the left

occipital regions and in the medial temporal lobe, and an increase

in arousal of these pictures was associated with activity in the right

caudate head extending to the nucleus accumbens and the left

dorsolateral PFC (e.g., Gerdes et al., 2010).

Gerdes, A. B. M., Wieser, M. J., Mühlberger, A., Weyers, P., Alpers, G. W.,

Plichta, M., et al. (2010). Brain activations to emotional pictures are

differentially associated with valence and arousal ratings. Frontiers in Human

Neuroscience, 4, 175.

Emotional networks…fear• Fear is particularly important for pain research.

• Fear conditioning research typically pointed to the

amygdala as the key neural structure.

• Fullana et al (2015) recently propose an extended

fear network that includes the central autonomic-

interoceptive network, i.e., anterior insula, dorsal

anterior cingulate cortex, dorsal midbrain,

thalamus, hypothalamus and pontomedullary

junction.

Fullana, M. A., Harrison, B. J., Soriano-Mas, C., Vervliet, B., Cardoner, N.,

Àvila-Parcet, A., et al. (2015). Neural signatures of human fear conditioning:

an updated and extended meta-analysis of fMRI studies. Molecular Psychiatry.

Pain-Emotion interactions • Emotions are strong modulators of pain, with

affective modulation of pain happening on spinal

and supraspinal levels

• Spinal modulations of pain by emotions are

mediated via the descending pain modulatory

system (ACC, PFC, PAG, RVM)

• Supraspinal modulations are mainly mediated via

the ventromedial prefrontal cortex (vmPFC),

nucleus accumbens (NAc), anterior insula (aIns),

and anterior midcingulate cortex (aMCC).

Wieser, M.J, and Pauli, P. (2016). Neuroscience of Pain and Emotion. In M.A.

Flaten and M. al'Absi (Eds). Neuroscience of Pain, Stress, and Emotion:

Psychological and Clinical Implications (pp. 3-27). Academic Press Inc:

Elsevier

Wieser, M.J, and Pauli, P. (2016). Neuroscience of Pain and Emotion. In M.A.

Flaten and M. al'Absi (Eds). Neuroscience of Pain, Stress, and Emotion:

Psychological and Clinical Implications (pp. 3-27). Academic Press Inc:

Elsevier

Neuropsychology of pain

• Descending pathways represent

the individual’s state of mind -

memories and experience, fears

and expectations, and mood.

• These modulate transmission

from the first synapse onwards.

• Cortical processing also draws

on memories, learning, current

state, potential action, etc.

• These systems are complex,

plastic and recursive.

Reacting to pain:

Health and the ‘disappearing body’

• When well, our bodies tend

to be ‘invisible’.

• We are not conscious of our

eyes that see, our legs and

feet that walk etc

• We are conscious of what

we see, feel, do, hope for,

plans etc

Our attention is normally focused on the world constructed

through our bodies, not on the body itself.

Reappearance of ill or hurt body

• Pain, iIlness, injury or dysfunction tends to focus attention on the body – even if relatively minor

• ‘I suppose it made me think about it, before I thought about what it looked like, whether I was putting on weight or what make up to wear, but never about what’s going on inside, never gave it a thought. I still don’t care about the bits that don’t hurt, but I know I’ve got a back now, and a bum and a left leg, because it hurts and you can feel it, like a solid thing, like something that’s gone wrong’

Lynette, age 32, chronic pain 9 years. In Osborn, 2002: 222

Illness

Impaired

function and

/or

symptoms

disrupt

activities

Health:

attention

and

energy

focused

on

activities

of living

Body

becomes

focus of

attention-

try to ‘fix

problem

It works

It

doesn’t

work

How is acute pain

different from

chronic pain?

What vicious

circles can

develop with

chronic pain?

Acute pain Chronic pain (>3/12)

•Short term

•Cause usually known

•Often injury related

•Goes away after healing

•Treatment usually

helpful

•Useful warning

•Long term

•Cause often unknown

•No ongoing damage

•Persists beyond normal

healing

•Treatment often little benefit

•‘Useless’ message

Hurt does not always

mean harm

How is acute pain different

from chronic pain?

Brain changes in chronic pain

• Transition from acute to chronic shows change

from acute pain circuitry to emotional/reward

circuit and this occurs within the first year.

Hashmi et al (2013). Shape shifting chronification in chronic pain.

•

Brain changes in chronic pain• Reduced activity and grey matter density in PFC and

thalamus - equivalent to 10-20 years of ageing

• Reduced blood flow to the PAG

• Representation of back in the somatosensory cortex invades

the leg area in CLBP and corresponds to pain chronicity

• Similar to neurodegenerative diseases

• Increased sensitivity to other sensations (e.g. sounds, taste)

• Changes to psychological tasks (Iowa Gambling test)

• Alterations in body perception - reduced proprioception, 2-pt

discrimination, graphaesthesia on the back

Living with chronic low back pain

• Loss of

– Socio-economic status

– Physical abilities

– Mental abilities

– Occupational roles

– Social roles

– Change in relationships

– Financial hardship

– Loss of current self worth

– Loss of hope and future

Walker et al. (2006). The experience of chronic low back pain.

European Journal of Pain. 10 (3) 199-207.

Pathoutofpain.com.au

The knowledge gap…• Chronic pain is a complex and poorly understood

condition incorporating sensory, cognitive and emotional elements.

• Research demonstrates a strong association between chronic pain states such as chronic low back pain and psychological factors such as anxiety, fear-avoidance, self-efficacy, catastrophizing and depression (e.g., Pincuset al., 2002; Carson et al., 2007; Costa et al., 2011).

• Until recently, the way in which chronic back pain sufferers process their emotions was largely unknown.

• The role of emotions in chronic pain can be explored using the Emotional Processing Scale (EPS-25) (Baker et al., 2007).

Research Aim

study 1 To examine the way in

which patients with CLBP

process their emotions

compared to a group of

individuals without a

history of CLBP.

If a relationship exists,

establish whether this

applies equally to all facets

of emotional processing.

Baker, R., Thomas, S., Thomas, P.W., Owens, M. (2007)

Development of an Emotional Processing Scale. Journal of

Psychosomatic Research, 62, 167 – 178.

Impoverished

Unregulated

EmotionAvoidance

Unprocessed

Emotion

Suppression

Emotional

Processing

Dimensions of the Emotional

Processing Scale (EPS-25)

Impoverished

Unregulated

EmotionAvoidance

Unprocessed

Emotion

Suppression

Emotional

Processing

Intrusive & persistent

emotional

experiences.

Avoidance of negative

emotional triggers.Inability to control ones

emotion.

Detached experience of

emotions. Poor emotional

insight. Potential to somatise

emotional experience.

Excess control of

emotions and expression.

Method – Study 1Design:

• Case-control study

Two participant groups:

• Control Group (N=55)

• Chronic Lower Back Pain (CLBP) Group (N=55)

Participants voluntarily completed the EPS-25

• A 25 item statistically valid and reliable questionnaire (p<0.01) (Baker et al,

2007)

• 5 core emotional processes

Participants also completed a biographical questionnaire

• All participants: age, gender, ethnic origin, etc.

• CLBP participants: duration, frequency and other sources of pain

Results – Study 1• CLBP patients scored

significantly higher in the

overall EPS-25 score [p =

0.00, d = 0.71, effect size =

0.33]

• A post hoc power analysis

revealed that the statistical

power for this study was

0.96 for detecting a

moderate to large effect

size.

Results – Study 1• Also significant differences in four factors:

– suppression (p = 0.00, effect size = 0.44)

– unprocessed emotion (p = 0.02, effect size = 0.23)

– unregulated emotion (p = 0.02, effect size = 0.22)

– impoverished emotional experience (p = 0.04, effect size

= 0.20)

Preliminary discussion• Preliminary evidence of a link between CLBP and altered

emotional processing, suggesting that those with CLBP

may be generally less able to process their emotions

effectively.

• Higher EPS-25 scores indicate relatively dysfunctional

emotional processing (e.g., Baker et al., 2007).

• Our results suggest that CLBP sufferers are more likely to

be ill-equipped to process their emotions than pain-free

individuals.

• An impaired ability to effectively assimilate upsetting

emotional episodes prolongs their effects and disrupts

subsequent experiences and behaviours (Rachman, 1980).

Research Aim – study 2

To examine the way in which chronic pain

sufferers process their emotions whilst also

measuring for anxiety and depression to

investigate their role in this putative relationship.

Esteves, J.E. and Hicks, O. (in preparation)

Method – study 2Design:

• Case-control study

Two participant groups:

• Control Group (N=27)

• Chronic Pain (CP) Group (N=32)

Participants voluntarily completed

• EPS-25

• Patient Health Questionnaire for Depression - (PHQ-9)

• General Anxiety Disorder questionnaire - (GAD-7)

• Chronic Pain Form (troublesomeness grid Parson et al (2006) – It incorporates a scale for each of the thirteen different body regions

Participants also completed a biographical questionnaire

– All participants: age, gender, ethnic origin, etc.

– CP participants: duration, frequency & other sources of pain

Results – EPS-25• Chronic pain patients

scored significantly

higher in the overall EPS-

25 score with a moderate

effect size [p=0.03, effect

size=0.38]

Results – EPS-25

• Also significant differences in all five factors:

– suppression [p = 0.01, effect size = 0.32]

– unprocessed emotion [p = 0.01, effect size = 0.33]

– unregulated emotion [p = 0.03, effect size = 0.29]

– avoidance [p = 0.005, effect size = 0.36]

– impoverished emotional experience [p = 0.02, effect size

= 0.30]

Results – Anxiety and Depression

• CP patients scored

significantly higher in GAD-7

scores with a medium effect

size [p = 0.02,effect size=0.31]

• CP patients scored

significantly higher in PHQ-9

scores with a medium effect

size [p = 0.003,effect

size=0.39]

Conclusion • Dysfunctional emotional processing and regulation is

associated with chronic pain, particularly low back pain;

anxiety and depression may potentially play a role in this

relationship.

• Our observed associations alone do not allow for causal

inferences to be made and the question of whether

dysfunctional emotional processing is a consequence or a

determinant of chronic pain is as yet not established.

• However, evidence from neuroimaging prospective studies

show that the transition from acute to chronic shows

change from acute pain circuitry to emotional/reward circuit

and this occurs within the first year.

Hashmi, J. A., et al. (2013). Shape shifting pain: chronification of back pain shifts brain

representation from nociceptive to emotional circuits. Brain, 136(9), 2751-2768.

Implications for Osteopathy (1)• Collaborate with other specialist practitioners - improved

emotional processing has been shown to be highly successful

in reducing emotional distress (Whelton, 2004).

• Manual therapy may affect the emotional domain through the

use of techniques aimed at reducing sympathetic outflow,

anxiety and depressive feelings (Lindgren et al., 2010).

• Alongside manual therapy, mindfulness-based approaches

are likely to play an important role in regulating emotional

processing in CP patients.

Implications for Osteopathy (2)• Osteopathic treatment provides a privileged entry-point to the

interoceptive system offering patients with chronic pain a solid

way-in to inner world of experiencing while serving as tangible

support.

• It enables patients to explore the nature of their experiences

and to trust their body as a source of tacit knowledge and

counter-weight the often hyper-cognitive ways of coping with

stress.

• Co-using evocative language and movement to explore and

express their inner self and emotions makes the embodied

self-awareness resonate as it appears in the present moment

(Calsius et al., 2016).

Calsius, J., De Bie, J., Hertogen, R. and Meesen, R., 2016. Touching the lived body

in patients with medically unexplained symptoms. How an integration of hands-on

bodywork and body awareness in psychotherapy may help people with alexithymia.

Frontiers in psychology, 7.

Acknowledgments

• Professor Roger Baker and his team at Bournemouth

University

• Hilary Abbey, Mike Ford, Laura Wheatley, Oliver Hicks,

Elaine Mathias, Yvonne Kirchner and Rachael Rollins at

the British School of Osteopathy

• Clare Mayall, Jill Green, Sam McInerney and Eva Winter at

Oxford Brookes University