Rachel Aaron, PhD, presents at the Johns Hopkins Department of PM&R’s Grand Rounds on July 27, 2022.
So I told uh Anna Gravis, this is her, her presentation last week was a really tough act to follow. Um I can guarantee you will not feel as relaxed after my presentation. But um I do hope that you'll be intrigued about the role of emotions and chronic pain. Uh So thank you for having me. Um Here today to chat about this topic. Nothing to disclose uh objectives. Uh By the end of this presentation, you'll be able to define emotion regulation and describe a model of emotion regulation and chronic pain. Uh You'll be able to identify areas of emotion regulation, difficulties that are common in chronic pain and you will be able to um understand the longitudinal relationship. So understanding how emotion regulation actually relates to pain outcomes. So a little bit of background, I think everyone here is very familiar with the fact that chronic pain is very prevalent. It occurs in about a third of Children and adults worldwide. Uh In about 10% of the population, we see a severe disabling chronic pain. Um But in general pain is associated with impairment in numerous domains including functional um functional impairment, vocational, social, psychological So, um folks here who work with patients who have pain, you know, are well aware that pain can touch many areas of a person's life in terms of mental health, mental health disorders are very common in chronic pain. So here you can see some ranges and some prevalence rates. We see rates of depression anxiety and PTSD that are much higher than the average population. So one thing that's really important to understand about pain is that pain has both sensory and affective components. So the experience of pain is not just defined by the no C section or the physiological change in the body, but it is also defined by the affective context that it occurs in. So an analogy that I give to patients all the time is this is sort of the difference between stubbing your toe and worst day of your life where, you know, if it's me, um maybe there's some tears, maybe there's some cursing, maybe it feels like a terrible injustice and it hurts a lot versus stepping your toe the same injury on the best day of your life. You know, maybe it's something you can make a joke about um can kind of laugh off, probably not as painful. So to understand pain, we have to understand the emotional context that it's happening in. Uh for this reason, a tremendous amount of research has gone into understanding how people with pain cope with those difficult emotional aspects of pain. You can call this pain coping. Um So very hot topic in pain. Psychology for a long time. A few examples of how people might respond to the distress of pain are with pain catastrophizing. So this is experiencing pain and then having um very negative cognitions about that pain. So things, it's like this pain will never go away. This pain has ruined my life. I'll never be able to be the partner or the parent that I once was. Um people feeling that pain and assuming or worrying that it must be something much worse. So this must be cancer. There must be something that doctors are missing. Again, if you work with people who have pain, you've heard this and you've seen this. Um So pain catastrophizing is one way people can respond to the distress of pain. Kind of on the other end of the spectrum. We have chronic pain acceptance, which is the process of accepting that pain is something in your life in your body and the act of going on with your usual activities despite that pain. And again, if you work with people with pain, you also see this end of the spectrum. Another one is fear of movement. So some people respond to the distress of pain by um avoiding movement for fear that pain is going to get worse, that they won't be able to tolerate it. Um So this is another way that people cope with pain. So hundreds if not thousands of studies in the pain psychology literature have shown that um greater pain catastrophizing, more fear of movement and less chronic pain acceptance are associated with worse pain, intensity, worse disability, um and worse mental health symptoms. So, the way that people are coping with pain is defining or influencing strongly their outcomes. For this reason, pain coping is a common target of pain psychology intervention. And a lot of our common pain psychology treatments have been developed specifically with pain coping in mind. So, for example, cognitive behavioral therapy for pain, among other things, addresses pain catastrophizing by teaching people to recognize those pain catastrophes, thoughts and generate uh alternative thoughts that are more neutral or realistic. So rather than pain is ruining my life, um Pain is getting in the way right now and it's not pleasant. Um But I'm working with my, my team to come up with a plan and I'm learning to get back to some things I care about. So things like that, um C BT may also address fear of movement by helping people develop sort of hierarchies of activity um of physical activity and help them slowly face that fear and get back into being more physically active. For example, uh other treatments like acceptance and commitment therapy, uh really hone in on that acceptance piece and helping people learn strategies to increase the acceptance of pain. This is all very important and understanding how people cope with pain has been really instrumental to understanding how we can treat people who have pain and help them live better lives. Um I'm interested in a contract that is a bit more broader than pain coping. Um So we kind of zoom out specifically from how people respond to the emotional challenges of living with pain. We get a construct called emotion regulation and emotion regulation refers to how we're managing emotions in our lives in general. Um So to be human is to experience a constant stream of affective or emotional information, we're always in some affective state and we are often engaging in strategies to either change or maintain how we feel. Um So this isn't a new concept for anybody here because we all do this all the time. So everyone here is familiar with having an emotion that isn't so uncomfort isn't so comfortable and trying to do things about that emotion, to feel less of it or possibly to feel more of it in the case of feeling more positive emotion. So, emotion regulation is a general construct that relates to how people are managing their emotional experiences, generally speaking. So surprisingly, not a lot of research in the pain world has looked at emotion regulations. This research has really honed in on how people respond to pain, but we don't know a lot about how people with pain are responding to other emotions in their life, like stressors at work or problems in their interpersonal relationships or experiencing a loss in their life. Um And I've always kind of suspected that people who have difficulty coping with pain, probably have difficulty coping in other areas too and that we might be able to harness this to improve intervention. Um So, although this, there hasn't been too much research here in pain, we know from the broader psychology literature. So if we zoom out from pain psychology and zoom out from rehab psychology and sort of take all of this field of psychology as a whole. Again, there are hundreds if not thousands of studies that show that people who struggle to regulate their emotions effectively um are more likely to have poor mental health outcomes and in numerous domains and also to have poor physical health outcomes. So for example, measures like cardiovascular health. So for this reason, emotion regulation in general is a common target of psychology interventions, broadly speaking. So with that background, I'll just review a few questions that really drive my research program. So I'm very curious to understand how people with chronic pain regulate emotions in general. Again, this is not something that we know a lot about. Um but I'm curious how people are doing it and how this relates to long term outcomes. And ultimately, my goal is to figure out how we can harness these principles of emotion regulation to improve pain treatment and expand what we're doing now by really focusing on pain coping. So I'm gonna show you three areas of research that I've been working on over the last few years that get at these questions and um that aim to lay this foundation of understanding the role of emotion regulation and pain. So first, I'll show you a theoretical review that my colleagues and I worked on describing emotion regulation and pain. Next, I'll show you findings from a meta analysis where we honed in on one very specific aspect of emotion regulation and pain and how that relates to pain outcomes. And then finally, I'll show you data from a, a large longitudinal cohort study that my colleagues and I have been conducting over the last couple of years where we've been able to test some of these theoretical questions empirically and start to parse the longitudinal relationship between emotion regulation and pain. So we can see actually how does this matter and how is this impacting outcomes? All right. So I'll start here with this theoretical review on emotion regulation and pain, which was published a couple of years ago in the American psychologist. So the goal of this review, we wanted to bring this model of emotion regulation to chronic pain because again, um this isn't something emotion regulation has a very rich theoretical history in the general psychology literature, but that model hasn't really been pulled into chronic pain. So the first goal here was just to pull in that model to the field of pain and think about how the data that we have in pain relates to this broader emotion regulation model. With the goal of really understanding what gaps there are in the literature. Um Another goal of this paper was to think about how emotion regulation might um help us understand people who have both chronic pain and problematic opioid use. So I'm not gonna spend as much time on that third point here, but I'll just give you some context that um problematic opioid use is defined as any use other than what's prescribed a little bit more background on emotion regulation. So, in the broader mental health general psychology, world, emotion regulation is recognized as a trans diagnostic factor. And what that means is difficulties with emotion regulation are thought to underlie a lot of different diagnoses. So, trans diagnostic. So the mental health literature shows that difficulties with emotion regulation help explain depression, help explain anxiety ptsd and substance use. And this is important because if we have one thing that underlies many different diagnoses, then we can target that one thing in treatment and see improvement in many different domains. So the premise of this review that I'm gonna show you uh was to extend this model to see could emotion regulation also be a trans diagnostic factor that helps us understand chronic pain and problematic opioid use. So this is the model that we pulled in from the broader emotion regulation field and adapted for pain. Um So I'll walk you through this here, the first step in choosing to regulate emotion. So sort of on purpose, deciding that you want to change how you feel, which is a lot of what we do in, in a psychology intervention. Um emotion regulation can also happen sort of without conscious awareness. But here we're really focused on when you make the choice to change how you feel, which again is often what we're teaching people how to do in psychology interventions. The first step is just noticing how you feel, right? You have to recognize that there's something there that you want to change or you can do something about it. So the first step is recognizing what you feel. And then at that point, you can consider different types of strategies to select and implement to then try to change that feeling and when you are changing your feeling or endeavoring to change your feeling, um there's a few different things you could do. You could down regulate meaning, feel less of something or you could up regulate meaning, excuse me, you feel more of something and you can regulate your negative affect or negative emotion and you can regulate your positive effect and positive emotion. So we put those things together. Um There are four things that, that we could regulate, we could try to down regulate negative aspects, which means feel less bad, that makes sense. We could try to up regulate positive aspects. So feel more good that also tends to make sense. Um A couple that might seem more counterintuitive that I'll build a case for you can also up regulate negative aspects to feel more of something bad or down regulate positive effects, to feel less of something good. Um So this is what intentional, explicit emotion regulation looks like, recognizing a feeling and then engaging in strategies to change how you feel in one direction or another. So, um I'm gonna skip this first box of motion identification. I'm gonna take a deep dive into in the next study that I present. So for this, um for this part, I'm gonna focus on strategy engagement. So what do we know about how people with pain are engaging in strategies to change how they feel? So we'll start with down regulating negative effect, feeling less bad. Um This one has by far received the most attention. This makes sense, we feel bad and we want to feel less of that. Um So I'll start by saying that people with chronic pain, it turns out have elevated negative effect. So compared to the general population, we see higher levels of negative affect in this population. And um again, if you work with people with chronic pain, this probably makes sense anecdotally. So a lot of research out there looking at how people with chronic pain try to reduce negative effects. And most of what's out there shows um use of strategies that aren't all that effective in the long run. So pain catastrophizing, like we talked about avoiding activities, avoiding scary things, feels really good in the moment, but it tends to catch up with us with time. It doesn't resolve the underlying issue and kind of to summarize what we found here. I I I pasted this graphic on the slide here. This is the fear avoidance model, which is a classic model in pain and it helps explain why some people go on to develop pain and other people don't. So I'm just gonna walk you all through this model because I think it kind of summarizes nicely what we know about down regulating negative effect. Um So people experience pain, either because of an injury, a surgery or just an acute pain episode that has no clear underlying source. Um people feel pain one way to respond to that pain is with a lot of fear or with pain catastrophizing. So assuming that pain needs something really bad, assuming there are gonna be very bad impacts on your life because of that pain, um that can lead to a fear of movement. So managing that pain catastrophizing by just avoiding anything that might make the pain worse. Um This makes people really tuned in or hypervigilant to their pain, um which again can cause them to avoid activities. Um This is where we sort of get into the all day on the couch scenario, you know, all day in bed under the cover scenario, you know, and as you all know, or can imagine, this leads to physical deconditioning, it leads to greater disability. Um And all of this is also a perfect storm for depression. So really kind of disengaging from valued activities um can lead to depression and of course, all of those things together then leads to to greater pain. So I'm not sure if you can see my my mouse here or not, but this is a, a vicious cycle. Um And all of this kind of boils down to a failure to down regulate negative aspect of each turn. Um And then just to show you sort of the path of recovery on the other end, you know, some people might have pain, um they have little or no fear about that pain. So they're able to confront the pain, go on with their life. Um And that promotes recovery um or, or resolution or just being able to live with the pain that lingers. Um So, as I mentioned before, this is a common target of intervention, we see these strategies. So we, we see strategies for helping people down regulate negative effect in our pain psychology interventions. Um And just briefly in the context of what we know about people who have both chronic pain and problematic opioid use. We see similar trends, uh maybe a little bit more pronounced um difficulties down regulating negative effect. And the other thing that we see that's, it's kind of interesting is that opioid use, um when use is prescribed or not has the effect of reducing negative effect. Um So this can become problematic for people who don't have other strategies to down regulate negative effects when they suddenly have something powerful that can do that. And that, that's um not to say that that applies to everybody or most people who um who take opioid medications. But once that, once a dependency develops, this can be one of the things that maintains it. So moving on to our next intuitive category, um up regulating positive aspects. So feeling better, uh feeling more positive emotions. So there's been over the past decade, couple of decades, kind of mirroring trends in the broader psychology literature. There have been a number of um strategies or short interventions to help improve positive effect. Um So a lot of the things again that we practiced in um Anna Gravis wonderful presentation last week. So a loving kindness meditation is something that can increase positive affect. Um other things that we tend to see in rehab and also in pain are benefit finding. So finding reasons why it's positive to have a chronic condition um downward comparison. So for some people, it can be helpful to think. Well, this could be worse. I'm happy that it's not worse, that doesn't work for everybody. Um but it does um help some people. And again, I'm, I'm sure folks have seen that anecdotally. Unfortunately, when you look at the impact of these positive psychology interventions in pain. Um We don't see robust effects so, so far, um we haven't really figured out how to harness this and intervention to have big effects for pain. But this is a new, um this is a new and burgeoning area of literature. So I expect we'll see more robust trials over the years. Um Just a quick note on people who have both chronic pain and problematic opioid use, we do see greater antonia, which just means less positive emotion overall. Um And we also see some evidence of altered natural reward processing, which just has implications for how positive emotion is experienced. Ok. So now we're moving into our counterintuitive categories here um up regulating negative emotions. So feeling more of something bad. Um So it seems counterintuitive, but in fact, experiencing negative emotions is a really critical part of healing and we know this from the broader uh psychology literature. So when we experience something traumatic or when we experience a loss, um there is a normal process of negative emotions that come up and when we see people try to push those emotions away to avoid those emotions, um it tends to um it tends to stay kind of suppressed and can come and it doesn't resolve. So this can lead to lasting problems. So like a metaphor that I use sometimes in treatments, it's like having a Coke bottle that you're shaking up and there's all this uh you know, fizzy fizz ss carbonation. Um And then when the cap opens, you know, it can be kind of an explosion and that's not how it works for a lot of people, but sometimes it does work that way. Um So, you know, all that to say that there is immense value in feeling negative emotions and when people push those emotions away that can cause problems. Um So what we know in pain is that that emotional avoidance or suppression? So, trying not to feel bad things is very, very common and there is growing evidence that interventions that help people experience that negative emotion can lead to healing. Um So for a long time, so you have looked at expressive writing and pain. So this is just essentially journaling, spending 10 minutes a day writing about the experience of living with pain. And this leads to some small but significant improvements in pain over time. This was one of the first research that was showing us that um you know, really facing and experiencing and expressing emotions can be healing and pain and can lead to improved pain outcomes. Um One of my mentors, Mark Lumley, who's at Wayne State developed the uh developed emotional awareness and expression therapy. Um And this is a traditional uh 8 to 12 8 to 12 session psychotherapy program that at its core, helps people recognize their emotions and learn how to express them to themselves. And to other people. Um This intervention does a lot of kind of going back into the past and finding some of those sort of unresolved negative emotional experiences. Um So this, this treatment is new, but there have been probably 5 to 6 R C T s published to date. And we're finding that this um emotional approach which differs a lot from sort of more traditional pain psychology approaches uh is leading to improved pain outcomes, improved mood outcomes. And every study that's included AC BT control has found that in many ways this therapy is actually outperforming um C BT. So these results from these clinical trials that are starting to crop up are showing us how important it is to help people um experience those negative emotions. Um not a lot done here on chronic pain and, and problematic opioid use. So I'll move on from there. So our, our second sort of counterintuitive category, feeling less positive emotion. Why would you want to feel less positive emotion? Um There are actually a lot of benefits or, or functions to this. Uh You might think about interpersonal if you've had a great day and you're talking to a partner or a colleague or even a patient, he's in a state of really negative effect. Um then you'll down regulate your own positive effect to meet them where they are. Um You know, another kind of example is like not laughing at an inappropriate joke in a professional setting. There's all kinds of reasons why you might actually want to feel a little bit less good or express a little bit less good in situations. Um Nothing really here in chronic pain, but some um things that we speculated, we thought this might have a role in setting realistic expectations about physical activity. Um So we, we work with patients to set goals about what types of things they want to engage in over the next week before we see them again. And sometimes people set very lofty goals that aren't terribly realistic. And so this might be an opportunity where there's room to kind of down regulate expectations a little bit. So just some, just some thoughts there. So, you know, all in all, just a few key takeaways from this work, we know a lot more about how people cope with pain uh than how they are engaging in general emotion regulation. So most of the data that I showed you related to um how people cope with pain. Specifically, there are a lot of limitations to what we know about cultural and developmental factors that really define the success of emotion regulation. Um And I'll just pick on pain catastrophizing for a minute uh in, in some cultures that have a more communal approach to regulating emotions. Um Pain catastrophizing can actually be a very normative way to sort of express one's emotions and feelings to other people and then elicit help in regulating those emotions. Um So there's some concern that pain catastrophizing has really been pathologize through this western lens. Um Similarly, developmentally, uh again, picking on pain catastrophizing, um pain catastrophizing might actually be a really normative way that little kids regulate their emotions because they don't have the awareness and the context um that an adult has to sort of create more balanced statements. And again, they're relying on other people to help them regulate those feelings. So they're kind of by expressing their fears, they're listing that help that we, that um they need. So there's a lot more that can be said about that, but I just wanna kind of highlight that this literature is very limited in that way. Um This literature is largely cross sectional, very little research has looked at emotion regulation and pain, basically. No longitudinal research has looked at emotion regulation and pain beyond pain, coping. Um And one that I just want to highlight here that I think is really important is that negative emotions are not always bad. So some of our traditional models assume that the goal is always sort of to feel less bad about something. Um And hopefully, I've, I've convinced you that there's some value to experiencing negative emotions and that has implications for the way that, that we treat things like pain and um psychology with the. It's a OK. Awesome. Yeah, I thought it was you um Eva if you could mute, please. Oh, my God, no problem. Thanks. Uh, wouldn't be a, a Zoom Grand rounds without someone typing up. No problem. Um, ok. So moving on. So, so one other small point that I'll make moving forward is I'm gonna shift the nomenclature a little bit. Um And rather than pain coping, we'll focus on, uh, I'll be using the nomenclature, pain specific emotion regulation and I'll be referring to general emotion regulation and based on our review of the literature, I think this reflects the theory. Um It's a little bit better. So we'll be using that moving forward. I'm gonna take a quick detour back to um to uh this emotion identification box. So we talked a good bit about how um we talked about strategies in pain and now we'll talk about uh emotion identification. So specifically, um Alexa, which is a specific um deficit in emotional identification, I'll, I'll define for you later. Um This study uh conducted a meta analysis looking at levels of Alexa in pain. So, um again, going back to this emotion identification box, um Alexis refers to difficulties identifying and describing one's emotional state and a preference for externally oriented thinking. So, um people, we all vary in how aware we are of our emotions. Um Often when I introduce this concept to people, they say like, oh, I, I know someone who is really bad at this or really good at this. Um So this is a construct, it's a, it's a continuous construct, we all fall somewhere along the spectrum. Um And the goal of this paper was to see whether people with chronic pain have higher alexia compared to people who don't have chronic pain. Um We used uh although alexia is continuous, we used a cut-off score for this. Uh And then finally, we wanted to see among people who have chronic pain is alexia associated with worse pain, intensity, worse pain interference, worse depression and worse anxiety. So I'll orientate a meta analysis if this is a new uh methodology for you. Uh So a meta analysis is where you pull data from independent studies uh and analyze together to determine an overall effect. So like in a single study, you would have participants in a meta analysis, you have studies and so you extract effect sizes from different studies and then you're able to pull all of those findings together to make a strong statement about what the literature is saying. So we developed complex strategies to identify certain strategies to identify every paper that referenced to Lexo Imia and any type of chronic pain. And we were looking for um any study, uh any chronic pain condition where Alexis was assessed in our case, every study we found um alexia was assessed with a particular questionnaire. Um So this is a Prisma diagram you see with meta analysis, you can see here just that we uh basically identified 1200 about 1200 studies. Um And we reviewed every abstract for potential eligibility. Then we reviewed full text and we round up the 75 studies that measured Alexis i in a chronic pain population. So then we were able to extract findings from each of these studies to draw some big conclusions. Um So the first aim was to understand whether Alexis Imia is higher in people with chronic pain versus control. So again, here we use a cut off score. Um And this picture that you see with the lines and diamonds is uh a funnel, a funnel chart. It, it's uh a way of visually depicting meta analytic findings. And essentially, each line here represents a study mean and standard deviation. So when we pull the effects across all of these studies, we see that in fact, alexia is higher in chronic pain with a very large effect size. Um So alexia is um much higher in people who have chronic pain compared to people who don't, which tells us that people with chronic pain are um more likely to have difficulties describing their feelings. So, the next question was, how does this matter clinically? So, among people with chronic pain, is alexithymia related to worse outcomes. Um And so what we found again, when we pulled correlation coefficients across every relevant study, we found that among people with chronic pain, alexithymia was associated with greater depression and anxiety. This this effect was medium in in magnitude and greater pain intensity. And and this effect was small in magnitude, but statistically significant. So overall in pain, um Alexa Imia is higher. So people have difficulties identifying and describing their emotions and people who have this uh who have more of this are more likely to have poor outcomes. Um So this is important, this is a part, a part of emotion regulation that is important and um that we may think about how to incorporate an intervention. All right. So now getting into some empirical data, so my colleagues and I over the past couple of years have been collecting data from a large group of patients with chronic pain across the United States to start to look at the longitudinal relationship between emotion regulation and pain. Again, this is something that we don't know a lot about. But we want to start to design rigorous longitudinal studies to be able to say that this difficulty with emotion regulation does or does not relate to this outcome uh with the goal of in in influencing treatment. So I'm gonna show you results from one published paper I published just recently this year in Journal of Pain and then one paper that's not published yet. But you can see it's close enough that I can share a screenshot of the title page. So we're very close here. Um So this, this uh study is comprised of adults with chronic pain across the United States. Um We recruited uh these people through Amazon Turk, which is uh a database of hundreds of thousands of research participants. Um We worked with a third party company who helped us identify screen people with chronic pain out of this large database, um and also worked with them to achieve a sample that was demographically representative of the broader chronic pain population. So we were able to over sample groups that were underrepresented in our um in our study in order to get a sample that was racially, ethnically and gender uh representative. So that part was important and we were able to, to recruit 1453 people at baseline. Um Our first baseline assessment was April 2020. This was a very fortuitous time to have a large online study um planned to launch um So that worked out well for us. And this database has also launched another series of papers where we're looking at the impact of COVID-19 on chronic pain. So I'm not talking about that today. But if you're interested, um we have a couple of papers published there and um have been able to, to make some, some strong statements about the impact of COVID-19 on pain because again, this study was just um scheduled to launch in April 2020. So we also gathered follow up data at three months, 12 months um and 24 months this, we just finished collecting. Um I'm not gonna show data from this today, but I wanted to just call it out. Um because it was thanks to A PM R P and R research grant that we were able to get that two year follow up data. So I wanted to give a shout out to that mechanism and thank and her team for making that available to us. All right. So in this large uh we, we administered a large survey to all of these participants at each of our four time points. And uh what we did were were to include measures of um pain specific emotion regulation. So, pain catastrophizing, pain acceptance, I think you're all familiar with that by now. Um Also a few measures of general emotion regulation. Uh The these, the selection of these measures were informed by our theoretical model. So here we have Alexa getting at emotion identification and then uh we have emotion approach coping, which is a way of of regulating emotions, it's responding to emotions by processing them and experiencing them. Uh We have reappraisal which is the strategy of um of restructuring negative or catastrophic thoughts to be more neutral or realistic and then suppression, which is that like trying to tamp them down, to feel less of it. Uh So we measured this at baseline and then we measured pain severity and pain interference at three month follow up. Um And our first question was OK, how do pain catastrophizing and pain acceptance? These pain specific emotion regulation measures relate to outcomes. Uh And we replicating a lot a lot of other literature. Um We found that greater pain acceptance was associated with less pain severity and less pain interference. Um We found greater pain catastrophizing was associated with greater pain interference. Um, not pain. That was a little strange. But, um in psychology, we, we, we're better at predicting disability and pain interference is a measure of how much pain interferes with your life. It's a form of disability. Um We're better at predicting pain interference than we are at pain severity. So it wasn't too surprising. Um And then we wanted to see, OK, well, when we add these general emotion regulation factors to the model, what happens, what changes? Um So we found, first of all, we found that the the association between pain catastrophizing and pain interference became nonsignificant. Um We think this is really important because a strong association between pain catastrophizing and pain interference is just a very, very robust finding in the literature that has been replicated over and over and over and over. And what we found here in our in our sample was that once you accounted for general emotion regulation, that relationship became nonsignificant. Um So again, these are initial findings, these are preliminary in need of replication, but it hints at the possibility that emotion regulation is tapping into something bigger are more broader, more relevant, more trans diagnostic um of the specific general emotion regulation factors. We only saw Alexis uh as as significantly predicting greater pain severity. So more alexia, more pain severity, more alexia, greater pain interference. Um I'll just make a note here that we use a rigorous um type of statistical analysis for these findings to be controlled. For absolutely everything that could have possibly influenced findings including baseline pain severity and pain interference. Um So we're able to have a lot of um confidence in these findings. Um Not to say that they're not in need of replication, but just to highlight uh that, that we're confident about these results in the current sample. Um So this first study um are the main takeaways are that general emotion regulation contributes to pain above and beyond pain, specific emotion regulation. I mean, it highlights the importance of assessing general emotion regulation alongside pain specific emotion regulation when we're trying to predict pain outcomes, which of course is a very important question in the pain field. OK. So study two. Um here, we're looking at 12 month outcomes and um this study was driven by a desire to understand how these different strategies claim together. So I've suspected for a while that people who um have greater pain catastrophizing, as I said before, probably also catastrophize in other areas. So I thought once we sort of put all of these things together and we see what different profiles of emotion regulation look like. I thought that we might see that people who have high pain catastrophizing um also have lower reappraisal as a general emotion regulation strategy. And I thought, you know, people who are better at pain acceptance are also probably better at emotional approach coping. Um So I wanted to see how do different levels of pain specific and general emotion regulation cling together cluster together. So in order to look at this, we did a latent profile analysis um to see how patterns of responses cluster together. So I'll walk you through that. Um Here you see the circles I've introduced you to these constructs already. These are sort of overarching constructs. Many um these are all questionnaires, many of them have subs scales underneath them. And so that's not terribly important, other than the squares represent different types of the circles. Um But what we did is we took all the squares and we uh ran a laten profile analysis which shows us whether there are specific groups in our sample that have particular patterns of responses. So I'll show you sort of the visual LP A analysis because this is kind of cool. But then I'll, it's also complicated. So I'll walk you through it. Um Basically, our LP A analysis showed us that we had four distinct groups within our sample of 1453 patients. Um and that they could be categorized based on their responses to these questionnaires. So just for example, one group in red had high alexia, high suppression and high pain catastrophizing. If you can see that on the chart, another group in blue had low alexia, uh high emotional approach, coping and low pain catastrophizing. Um So this doesn't need to make sense, but just kind of visually show you what this type of analysis gives you um to synthesize all of this. Our four groups can be described as people who have difficulties with general emotion regulation. Only this captured about a third of our sample. And these were people who had, for example, high lexo imia, high suppression and low emotional approach. So, not great ways to um to regulate emotion in general. Uh And we didn't see evidence of difficulties with pain, catastrophizing or pain acceptance. Our next most common group were people who had difficulties with both pain specific and general emotion regulation. Um So here we see again, some, not the best ways to regulate emotion, high alexia, high suppression, low emotional approach. Um And we also see high pain catastrophizing and low chronic pain acceptance. The next most common group, about a quarter of our, of our sample were skillful in both pain specific and general emotion regulation domains. So these people were um unlikely to, they, they were um had low alexia, they were unlikely to use suppression. They had good emotional approach coping. And they also had low pain catastrophizing and high chronic pain acceptance. And then finally, the least common group were people who had difficulties with pain specific emotion regulation only. Um So that's a lot. But a couple of key takeaways here. So, um so this is, this is not what I was expecting to find. I didn't expect our groups to sort of split based on general emotion regulation versus pain specific emotion regulation. I thought we would see trends across um different types of strategies. Like I kind of said before, I thought maybe we would have a more express group that was high on emotional approach and high on chronic pain acceptance. But that's not what we found. Um the results from this study again, a single study that needs replication suggests that pain specific emotion regulation and general emotion regulation may actually be independent. Um This has a lot of implications for intervention because it might be that people who have um for example, difficulties with both pain specific and general emotion regulation. Difficulties might benefit from traditional pain coping treatments that add on more general emotion regulation pieces. Um People who only have difficulties, pain specific emotion regulation might benefit from just that traditional pain coping approach. And it may be that people who have just difficulties with emotion regulation in general but not in pain, they might benefit from more uh mental health treatment that has a, a bigger focus on general emotion regulation. So a couple of other takeaways here, um most people in our sample had difficulties with general emotion regulation. Um So this, I was excited to see this in the sense that it fits my story, that emotion regulation is difficulties with general emotion regulation is super relevant for this population. So we're not just talking about problems managing the distress associated with pain. Um Here, we're seeing problems regulating emotions in general. So we see um a lot of Alexa Imia in this group, we see high suppression. So people just trying to push the emotions away and that low emotional approach where they don't want to approach and feel the emotions, talked about how this could lead to poor outcomes. Um About 25% were resilient uh with skillful emotion regulation in both domains. This mirrors the broader literature. Um that many people with pain are, are resilient and can cope with pain and other stressors in life just fine. Um Interesting that people who had only problems with pain specific emotion regulation were the least representative um which is important because this is what our interventions are targeting. OK. So the next question here was now that we have these groups. How does this relate to 12 month outcomes? Um So one year later, people who fall into these groups at baseline, um what does their pain look like in one year? And what does their depression and anxiety look like in one year? So what we were able to do again using robust S E M analysis, controlling for everything we could possibly control for. Um we were able to rank uh which groups had the worst outcomes. So I'm just gonna summarize a few trends here. Um people who had challenges regulating both pain and general emotions had worse outcomes across the board. So these, these people um again, even controlling for baseline factors, membership of this group predicted worse pain severity at one year and worse pain interference at one year. So people who belong to this group were likely to deteriorate in these areas. Um Same with depression and anxiety, interestingly for pain outcomes. Um The other groups weren't differentiated on outcomes. So we see that uh people who had difficulties with either pain or general or were skillful in both um were were all the same when it came to pain, severity and pain interference. It may be that skill in one domain, protects against outcomes in pain, severity and pain interference. Um For depression and anxiety, the pattern was a little bit different uh where we saw people who were skillful and both had the best outcomes. So we see that protecting against depression and anxiety requires skill in both domains which again has some implications for treatment. So that was a lot. Um And I think we've kind of already, you know, I've kind of already summarized the main um points here. Um But there's a lot that we can think about these Friday for how we might um think about treatment in the future. A number of limitations to this research that are important to note, as I continue to say, this is one sample, this has not been tested before. Um There's need of replication. This was all questionnaire based. Um and uh questionnaires that people completed at a single time point at, at four different times, but at a single time point. So what we really want to for assessing emotion regulation is we want to be able to get a lot of assessments, for example, over the course of a day. So we see how emotion regulation unfolds. This is very resource intensive, but this is the future direction of this work. Um You could argue for different theoretically driven questionnaire batteries. Again, this is sort of the first step to get at this question. So in summary, difficulties with emotion regulation in general are common in chronic pain and lead to poor outcomes. And there may be benefit in expanding those traditional pain psychology treatments that really hone in on pain coping to expand to, to address general emotion regulation, pulling from what we know from the broader psychology field, particularly for people who have those difficult. We may even be able to phenotype people based on their emotion regulation profile and tailor treatment in that way. Again, these are all many future directions that could come from this work. Um So just to highlight a few future directions that I'm currently working on, um I didn't talk too much about it, but there are a lot of other problems with the way we assess emotion regulation and pain and in general, um So, um for example, the Alexis Ionia measure that's commonly used has many limitations. So, my colleagues and I are currently validating a new measure of alexia that's thought to be more um psychometric sound in the pain population. So we're excited to see. Um Well, I can tell you it is more psychometric sound. So um we're excited to have a potentially better measure of Alexis to put out there. Um As I said, intensive longitudinal sampling, which is just that getting repeat assessments over the course of the day. Uh So I'm very interested moving on um to how these models apply to relevant rehab populations. So I have a really strong interest in orthopedic trauma and understanding how emotion regulation um plays out and predicts outcomes after a trauma and orthopedic trauma, which is um almost always very painful and also uh is almost always very emotionally distressing. Um So we are, we're doing a pilot study right now in orthopedic trauma at Hopkins um to test these same models in um this population and see how emotion regulation six weeks after a trauma predicts six month outcomes. So, moving on the long, long term goal here is to use these study findings to inform intervention. So a couple of things, my colleagues and I are working on, uh we're, we're analyzing the massive literature looking at depression and anxiety and pain. Um There's not a lot of consensus actually on how common um different mental health disorders are in pain, although we know it's elevated. Uh so we are um synthesizing all of the literature. So we can make some strong statements about what prevalence looks like, what prevalence looks like across different populations. And then we can start to think about um how we might help treat people who have both pain and depression or both pain and anxiety. Um And again, sort of considering emotion regulation as a potential trans diagnostic target. Uh Finally, I have some pending grant funding to test a specific emotion focused therapy for emotion for Ortho trauma to see how that improves outcomes. Um So just some quick um acknowledgements, not enough time to thank everybody, but I want to give a special thanks to my mentors uh Steve here, Claudia Campbell in Psychiatry and Mark Lumley at Wayne State. Um And I have to thank my collaborators, Cheung Ju Moon who goes by moon, who's at Arizona State. Um He's been instrumental helping get the large in inter study off the ground and responsible for any fancy statistical analysis that I showed today uh has not actually reflected on these specific studies I showed, but he is entirely responsible for launching every single feature direction of this work. So I have to thank um finan for um supporting this work and, and really helping uh helping take it to the next level. Uh Lake and our own family um has also helped with the studies Lakia Miguel uh Patrick Fein in Psychiatry and uh my friend Emma Fisher who has taught me everything about that analysis. Um A few grants to think here. Uh And again, I want to give us a special shout out to the PM and R research Steve grant which funded the two year follow up. So I'll just um conclude with a picture uh here and say, thank you. This is this these any stock photo I could find of emotion regulation. This is my son looking at a picture of a, a book that says, look at the happy baby. Can you make a happy face? And he is clearly not making a happy face. So there's a lot that um that babies have to learn about emotion regulation as well. So I will cut that off and welcome any questions that you all have? Thank you, Rachel. I I it was a great talk and uh can you hopefully you can hear me? Um great, great presentation and very interesting um data I have, I mean a question about uh I'm just happily surprised and I wanna highlight the, they use the um the Amazon Turk to as a platform to to launch a healthy thing. Um um People in my group have been doing that for doing motor control and so on. So I'm amazed the flexibility of this platform. Is there any concern about that? Like in terms of uh the type of patients that you get like sexual bias because you are using that type of platform. And uh you get people who maybe are savvy in Amazon, which I never heard before until somebody and the younger generation and so on. Can you? Yes. Thank you, Pablo. That's a great question and um an important part of our methods. So um so we did, we worked with us. So a couple of things, we worked with a third party company which made this research expensive. Whereas uh in can be cheap, this was not cheap because we worked with a third party company who helped um put in a number of stops to ensure quality data. Um So through mturk, people have a quality rating. So we only took people who had a very, very high quality rating, um we had embedded in our survey attention check. So people have to say, you know, please select never true. Um And anyone who fails a single um attention check is excluded from the database altogether. Um We also have other stops. So for example, people who um we do pilot testing to figure out how long the survey can take and people who complete it too quickly are excluded and it's a pretty conservative cut off and people who take too long are excluded. Um So these are some of the strategies that we've put into place. There's some good validation studies now that show that M Turk data um is as valid as in person data or in some cases even exceeds the validity of in person data as long as you're applying these stocks. Um So I would say it made it a little bit more complicated, but we were able to put some um sort of practices in place to, to promote high quality. But that said, you know, you never know what you're gonna, what you're gonna get. And, and in terms of uh age do they, is this, I mean, you, I presume you had that information is, are you just testing a younger group of the population? Um So this is where we were able to um use over sampling. So we did achieve, so we have a really good representation um of age and of of household income. Uh So we have a, we have a good range of age, household income and then we were able to demographically match on race, ethnicity and gender. So when we compare this to studies that have looked at chronic pain in the general population, our sample looks very close to that. So we were able to, to recruit a sample that looks very similar, which is another reason why this wasn't a cheap way to do Amazon. That's great. Those are great questions. Thank you. And these are challenges that that people experience as we move science to test it online. And so, but fantastic. Thank you. Very nice work. Thanks very, very important methodological point. Thanks for bringing those up. I see. And Steve hands up and Mike off. Oh Nicole, sorry, Nicole. I let you go ahead. Go ahead. Go ahead. Hey, hey, well, uh first off, uh Doctor Aaron Rachel, I wanted to thank you uh very much for the presentation. Great job. Um And I had some curiosity about um one of the future directions that you proposed. Um one of the future directions proposed was related to this emotion focused therapy that you're interested in pursuing in the orthopedic trauma sample. And, and in the presentation, you noted that there were a number of different kinds of emotion regulation abilities um that can be targeted or multiple could be targeted at once. There's the the pain specific and the more general. And I'm just curious when it comes to the emotion focused therapy. Um Is there any work published by um the author out in Wayne State? Um to demonstrate that it's maybe working on spec some of these specific mechanisms, these specific um underlying emotion regulation processes. And if not, um do you have any hypotheses on, on what particular it might be working on? Yeah, that's a great question. Thanks. Um So there are I believe planned mediation and moderation analyses out of these clinical trials to be able to look at that. Um Those to my knowledge have not been published yet. Although I can say one interesting mediation finding that was published uh is they were able to look at changes in central sensitization Um So in, in chronic pain, central sensitization is uh one reason that thought to lead to chronic pain, particularly pain, that doesn't have a clear biological source. And that just has to do with sort of overly sensitive pain processing in the body. And um those types of pain conditions are thought to be particularly responsive to these more emotion focused treatments. And so they have been able to show that improvements in the treatment overall um are in part attributed to improvements in central pain processing. So speaks to the sort of more biological mechanism of how psychological treatments, especially emotion focused treatments are helping with pain. Thank you. Cool. I was gonna actually go over to David who has his hand raised. He's a physical therapist. Let a different discipline get, get in. Thanks. Um This was great, by the way. So thanks so much uh for presenting this, uh especially with your last comment about central sensitization. I was super curious about how we could maybe screen for this with patients that we think would benefit from this. Uh The one thought that's coming to mind is I struggle sometimes and maybe I'm picking this up because I don't wanna sound like um uh I feel like it can kind of be a sensitive thing to question someone's emotional regulations. So I'm just thinking all the thoughts in my head about how we could get them help and make them feel safe in the process. And not like confronted for. Like in other words, that's a really, really good point. David, thank you for bringing that up, especially as we think about kind of phenotyping and these things can be very stigmatizing, right? No one. And in fact, there's a movement in the broader pain psychology field to move away from the term pain catastrophizing because patients, there have been studies qualitative studies that show that patients find that can find that very invalidating. Um And so I think certainly this is really, this work is really at the beginning stages. And I think the long term goal is to sort of personalize treatment. But I think best approaches in terms of, you know, when we see a patient in distress and we know they need help in some kind of way. I think normalization is the best approach. So just explaining that living with pain is really hard for anybody and that there are some strategies that might be available to help them learn how to live with pain a little bit better. So just really normalizing the distress and normalizing, getting, getting some help in, you know, in our department, I think it's always helpful to emphasize the interdisciplinary nature of how we treat pain. So, um you know, depending on the patient may be pulling on the science to say, you know, research shows that your best shot at improving pain is targeting it from all the different angles, right? So you've got your medical approaches and you've got your physical the therapy approaches and you've got your psychological approaches and that's really how we see the biggest bang for our buck when it comes to learning how to live with pain. Ok. Thank you. Thanks David. Great question. Just very quickly. I mean, I think just more broadly, Rachel, I mean, obviously great. It was a wonderful presentation and very nicely done, great graphics. I mean, one thing I want to bring attention to is what Rachel is doing here is reminding us of something that we forgot, right? We got very, you know, psychology, everyone's very focused on emotion and talking about emotion and everything. And then we got all focused on cognitive factors and behavioral factors and the emotion got lost. And what Rachel is doing is saying, hey, the thing that was really important before we kind of got lost. Let's bring that back. And I think this is, you know, we think about advancing research in any area. Sometimes a good thing to do is to say, what have we left behind that may we need to maybe to bring forward to explain variants, right? Because what's happening is the cognitive factors, the behavioral factors, the very the variance they explain is not large, but by adding emotional factors and we account for more variants. And I think the fact Rachel you reminds us of what we forgot and reintegrate that is, is brilliant and um that's often is a way forward, right? Is remembering what we forgot. Thank you very much, really appreciate this kind of presentation. Thank you, Steve. All right, I see. It's one o'clock. Thank you all. I I'm always happy to talk about this more. So please let me know if you have other questions. And um yeah, thank you all for being here. Hope you have a good day.