Friday, February 4, 2011

The Interpersonal Side of Pain: Emotions Reign!

Pain EmotionsEmotional 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 Johns 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. However, 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 [see UPDATE discussion here].

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 MacDonald 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 MacDonald 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 [UPDATE discussion here], 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 [discussed in UPDATE here]. 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 [discussed here] — 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.

> Barsky Reese J, Somers TJ, Keefe FJ et al. Pain and Functioning of Rheumatoid Arthritis Patients Based on Marital Status: Is a Distressed Marriage Preferable to No Marriage? J Pain. 2010;11(10):958-964 [
abstract here]
> Borsook TK, MacDonald G. Mildly negative social encounters reduce physical pain sensitivity. Pain. 2010;151(2)372-377 [
abstract here]
> Cripe SM, Sanchez SE, Gelaye B, et al. (2011), Association Between Intimate Partner Violence, Migraine and Probable Migraine. Headache: J Head Face Pain. 2011;51(2): 208–219 [
abstract here].
> Raichle KA, Romano JM, Jensen MP. Partner responses to patient pain and well behaviors and their relationship to patient pain behavior, functioning, and depression. Pain. 2011;152(1):82-88 [
abstract here].
> Sambo CF, Howard M, Kopelman M, Williams S, Fotopoulou A. Knowing you care: effects of perceived empathy and attachment style on pain perception. Pain. 2010;151(3):687-693 [
abstract here].