Interpersonal Side of Pain: Emotions Reign!

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Interpersonal Side of Pain: Emotions Reign!

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<http://updates.pain-topics.org/2011/02/interpersonal-side-of-pain-emotions.

html> Interpersonal Side of Pain: Emotions Reign!

Emotional support can be an important component of a successful treatment

plan for any chronic pain condition. Conversely, a lack of support or the

wrong kind of emotional support might drive increased physical pain and

disability, and the underlying psychosocial dynamics at work may not be

readily apparent to practitioners.

Many healthcare providers may consider the interpersonal, emotion-laden

relationships affecting their patients to be outside their purview of

practice, even though overlooking or disregarding these influences might

thwart effective pain management.

The scientific literature from disciplines such as psychiatry, psychology,

and sociology discusses at length how interpersonal relationships may affect

a person's pain perception, physical disability, and emotional adjustment.

While the research has raised many important questions, few definitive

answers have evolved; still, this is a vital, albeit complex, area for pain

practitioners to be aware of and to contemplate in everyday practice.

Following, is a sampling of recently-published studies that highlight the

relevance of these issues.

Strong Marriages May Soothe Pain

Researchers from s Hopkins and other universities in the United States

examined how both marital status and marital adjustment related to pain,

physical disability, and psychological disability in 255 adults with

rheumatoid arthritis (RA) [barsky Reese et al. 2010].

Among married participants (n=158), better marital adjustment was

significantly correlated with less pain as well as less physical and

psychological disability.

, patients who were either in " distressed " marriages or unmarried (n=97) had

comparably greater pain and disability.

These findings suggest that being married in itself is not associated with

better health in RA but that being in a well-adjusted or non-distressed

marriage is linked with less pain and better functioning.

However, pain and marital status were measured concurrently in this study;

therefore, the data cannot confirm whether a happy marriage actually

alleviates RA pain and disability, or if greater pain and disability

destroys relationships, or if poor relationships directly increase pain and

disability.

Still, it is important to note that prior research demonstrated that

favorable romantic relationships - characterized by intense feelings of

elation, well-being, and preoccupation with the person of affection - may

activate reward systems in the brain that help to counter pain

Therefore, despite the limited conclusions that can be drawn, the clinical

question is whether patients' relationships with loved ones are something

that pain practitioners should take into account, and recommend couples

counseling for those who are in unhappy unions (whether marriage or a

domestic partnership).

Negative Encounters Stifle Reports of Physical Pain

Psychologists at the University of Toronto demonstrated that the nature of

social interaction surrounding a person with pain may influence the

individual's sensitivity to physical pain [borsook and Mac 2010].

In their study, healthy participants (n=45) rated the intensity and

unpleasantness of painful stimuli before and after engaging in a structured

interaction with a trained actor who was either warm and friendly or

indifferent and aloof throughout the exchange.

Participants experiencing the indifferent social exchange, which was

somewhat stressful, reported less sensitivity to pain after the interaction

compared with baseline.

Whereas, pain sensitivity in those exposed to the positive social

interaction was generally unaffected.

One would think that a favorable social interaction would be comforting;

however, the authors note that the analgesic effect of a socially

disconnecting exchange may result from the well-known fight-or-flight stress

response, of which pain inhibition is a typical component.

This may be further exacerbated in sensitive persons who already feel lonely

or fear rejection.

There also are significant implications here for clinical interactions:

Borsook and Mac suggest that health practitioners who are aloof,

convey a lack understanding, or are generally unresponsive to patients may

provoke a temporary hypoalgesia leading to grossly understated reports of

pain by patients.

As an unintended consequence, insufficient pain-control measures might then

be prescribed for such patients.

Pain Perception Affected by Caring Others

As noted in the above studies, other people can have a significant impact on

one's pain perception. However, in the complex world of emotions,

psychological factors within the individual also can play a role [sambo et

al. 2010].

Researchers in the UK studied whether the presence of other, empathic

persons can modulate subjective and autonomic responses to pain; and whether

these responses also are influenced by the individual's pain coping and

social attachment styles.

A small group of participants (n=30) received painful thermal stimuli and

were asked to rate their pain. Then, they again received the painful

stimulus in the presence of either a high-empathic and low-empathic

observer.

Empathy was defined as the participant's perception of the extent to which

the other person understood and shared their pain. In a third condition no

observer was present (alone, control condition).

The researchers found that subjects scoring high on " attachment anxiety " had

lower pain ratings when in the presence of an observer having high empathy.

Attachment anxiety was characterized by increased worry over or sensitivity

to the responsiveness of others.

On the other hand, subjects with " attachment avoidance " traits - eg, a

preference for independence and self-reliance - had lower pain ratings when

alone than when in the presence of another person.

Interestingly, however, autonomic measures (such as, skin conductance and

heart rate) were increased in response to pain when any participants were

alone. That is, despite what subjects self-reported, which was influenced by

their attachment styles, their physiologic responses indicated that the pain

was reduced by having another person present.

This was a small, complex, study requiring careful interpretation. The

clinical take-away message appears to be that a patient's self-perception of

pain in the presence of other persons may be strongly influenced by

psychological traits.

In certain patients, the presence of other persons actually may exacerbate

self-reported pain; whereas, in others the pain may be soothed by the

presence of an empathic other. However, in terms of autonomic physiological

response, the mere presence of another person seems to attenuate the

reaction to a painful stimulus.

This line of research further suggests that pain may relate to primal

responses originating early in a person's development (soon after birth or

perhaps even earlier).

Research has found that other persons can provide comfort by their touch

and, possibly their mere presence which may supersede personality traits

that appear later in life, and this has implications for how pain

practitioners could better relate to their patients in clinical settings.

Pain and Function Impacted by Patient-Partner Interactions

Researchers at the University of Washington, Seattle enrolled 94 patients in

a study to examine how patient-partner (eg, spouse) interactions affect

patient-reported pain, illness behavior, and physical dysfunction [Raichle

et al. 2011].

As might be expected, if a partner encouraged wellness behaviors in a

patient the patient had lower levels of self-reported pain, whereas negative

responses to wellness behaviors resulted in greater patient physical

dysfunction. Negative responses in this case included discouraging a

patient's attempts at activity or criticizing an optimistic outlook toward

the pain condition.

Furthermore, a partner's negative responses to patient pain behaviors, as

well as solicitous responses to pain behaviors also were related to poorer

patient functioning.

Such negativism included criticism of the patient's acting out pain or

illness behavior, and solicitous responses included expressing concern about

the patient's ability to carry out activities or actually taking over

activities for the patient.

Interestingly, overall relationship satisfaction was rather high among study

participants, but this did not appear to diminish the deleterious partner

behaviors noted above or patient-reported pain behaviors.

Overall, this study points to the importance of how partner responses to

patient behaviors - whether to well behaviors or pain behaviors - can affect

patient pain and disability.

Even in the best of relationships the partner without pain may

unintentionally exert negative influences on the patient, which may confound

the clinical presentation of pain and dysfunction as well as response to

treatment.

Association of Partner Violence and Migraine in Women

Investigators recently reported interviewing a large sample of women

(n=2,066) regarding their lifetime experiences with migraine headaches and

an association with physical and/or sexual violence [Cripe et al. 2011].

Compared with women without a history of violence, women who had experienced

both physical and sexual violence, as well as either physical or sexual

violence alone, had significantly increased odds of migraine headaches.

The severity of physical violence did not affect the odds of having

migraine; however, having depressive symptoms did increase the chances of

migraine in the women.

Further analyses found that sexual violence afflicted by an intimate partner

was a particularly significant risk factor for migraine.

It is important to note that the cohort for this study included Peruvian

women who were interviewed during their hospital stays following childbirth;

so, the external validity of the findings in other populations needs further

investigation.

However, this study does raise important questions about the possible role

of physical and sexual violence in the development of migraines in women,

and in select cases this could be an important clinical consideration for

effective treatment planning.

The Pain Practitioner's Dilemma

Physical pain is largely a subjective phenomenon modulated by signals

traversing the same limbic areas of the brain that control emotions; merely

hearing discomforting pain-related words from others can fire-up the brain's

pain centers

So it is not surprising that relationships with other people - including

either repressed or dynamic memories of past encounters that have caused

unresolved emotional distress - may have a strong impact on pain perception

and functionality.

Unfortunately, the research evidence to date is rather muddled in some cases

by small-scale studies and/or multifaceted psychological constructs that are

often somewhat theoretical; therefore, the exact mechanisms at work and the

best approaches for dealing with these issues within the context of pain

management are unresolved.

All of this greatly complicates the clinical picture of pain for those

healthcare providers who are aware of and sensitive to such concerns, and it

emphasizes the importance of favorable practitioner-patient interactions

that facilitate rather than hinder the therapeutic process.

Many healthcare providers may feel that they have no business questioning

the personal lives of their patients, or have little time or training for

venturing into the psychosocial side of pain.

Yet, to overlook or disregard this vital area may risk therapeutic failures

that have little to do with the effectiveness or appropriateness of

prescribed pharmacotherapies or other interventions, and everything to do

with the patient's interpersonal and emotional milieu.

This poses a dilemma for pain practitioners and all other healthcare

providers who treat patients with pain.

At what point, and in which patients, should referrals for

psychological/psychiatric consultation be made?

Should the patient's partner (spouse or significant other) be involved as

well?

Then, of course, there also are two other questions:

Are such services available?

Are they affordable?

There do not appear to be good answers but the questions are worth

pondering!

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