Interactions between self-reported pain intensity and affects in daily life: a pilot study comparing individuals with chronic pain with primary and secondary pain disorders

doi:10.21203/rs.3.rs-2581714/v1

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Interactions between self-reported pain intensity and affects in daily life: a pilot study comparing individuals with chronic pain with primary and secondary pain disorders

https://doi.org/10.21203/rs.3.rs-2581714/v1

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Background and objectives:

Chronic pain is frequently associated with depression and anxiety disorders. A relationship between affects and pain intensity in everyday life has been previously documented using Ecological momentary assessment technique (EMA) with a particular focus on the exacerbating effect of stress and depressive symptomatology on pain intensity in daily life of specific samples of chronic pain patients. With the introduction of the new category of chronic primary pain in the ICD-11, which is strongly characterized by emotional distress, it is interesting to compare primary and secondary chronic pain patients with regard to the relationships between pain intensity and affects in everyday life.

Methods:

Here, 16 individuals with chronic pain (primary pain, N=10; secondary pain, N=6) completed a pain diary during 2 consecutive weeks, 3 times a day, within fixed time periods (morning, midday, evening). Self-report questionnaires were used to measure depressive symptomatology and anxiety. Momentary affects were grouped as positive and negative affects. Data analyses were performed using mixed model and Pearson’s correlation analyses.

Results:

Independently of group, individuals reporting more positive affect reported significantly lower pain intensity. Individuals in the primary pain group tended to report higher pain intensity compared to the secondary pain group. Exploratory analyses indicated significant correlations of pain intensity and depressive symptoms, and of pain intensity and affects only in the group with primary pain.

Conclusions:

Despite their preliminary nature due to the small sample size, our findings indicate a general beneficial effect of positive momentary affects on pain intensity in daily life. They also provide first evidence for differences in the perception of pain intensity between primary and secondary chronic pain patients with regard to the relationship between pain intensity and affects.

Biological sciences/Psychology

Health sciences/Rheumatology

self-reported pain intensity

positive and negative affect

ecological momentary assessment technique (EMA)

primary pain disorders

secondary pain disorders

With an estimated prevalence of up to 40%, chronic pain, i.e. a pain lasting for more than 3 months, is regarded as a major health problem with approximately direct and indirect costs up to 5% of the gross national product in western European countries [1]. Only in Europe, nearly one in five individuals reports having experienced moderate to severe pain at least twice a week in the previous month [2]. The fact that the number of people suffering from a chronic pain condition is steadily increasing [3], in spite of the overall improving standards of health care, emphasizes the urgent need for novel insights informing better diagnosis, prevention and treatment of patients with chronic pain.

Chronic pain markedly decrease individuals’ health status and quality of life (QoL) [4] and is linked with a wide range of physical and mental problems. Examples include as depression, anxiety and sleep disorders, and alcohol or substance abuse, either as antecedent conditions or as consequences of the development of pain [5], whereas depression and anxiety disorders are the two most frequent mental health conditions associated with chronic pain [6–8]. Furthermore, comorbid depression or anxiety is a predictor for poorer treatment response, prognosis, and social functioning, as well as higher levels of functional limitations and disability [7, 9, 10].

Several forms of chronic pain conditions have no clearly identified biological origins. In order to support the development of individualized pain management plans and to create a more accurate description of chronic pain conditions for clinicians and researchers, the 11th edition of the International Classification of Diseases (ICD-11) has introduced the category of primary chronic pain, based on the terminology of the International Association for the Study of Pain (IASP) [11, 12]. Because primary chronic pain conditions are characterized by significant emotional distress or functional disability within a multifactorial biopsychological etiological framework and independent of identified biological or psychological contributors [12], the investigation of affective processes and mental health conditions in these disorders might yield a better understanding of the psychological processes involved in these conditions.

Self-reporting of pain is crucial for pain management. Physicians often need to know the location, intensity and quality of the pain, its impact on the patient’s activity, psychological functioning, and life in a structured format, as well as the course of the pain levels throughout the inter-visit time [13, 14]. Ecological momentary assessment techniques (EMA) are a well validated method for investigating individuals’ real-time experiences as they occur in their natural environment and situations over time, reducing memory bias [15]. It marked a notable advance in the measurement of the individuals’ every-day-pain-experience by providing data largely inaccessible to standard laboratory protocols as well as to characterize complex within-person processes over time [15–17]. EMA can be implemented to assess self-reports of pain in daily life with the help of pain diaries in digital or paper form [13, 17]. EMA has been used very infrequently to construct outcome measures in chronic pain intervention research [18], which is surprising in the light of the potential of EMA to provide ecologically valid estimates of treatment effects. EMA has been recommended for outcome measures in clinical trials to measure changes in actual pain experiences that are not confounded with symptom recollections and enhance understanding of clinical outcomes [19].

Because of the frequent association between chronic pain and affective disorders, several previous studies have used the EMA methods to investigate the association between pain intensity and affects in daily life in different samples of individuals suffering from chronic pain. Some of them focused on specific positive or negative affects, for instance, showing a significant effect of behavioral anger expression on increased pain intensity in patients with chronic lower back pain in the subsequent assessment period [20], or reporting that the worst pain experienced in everyday life was, among others, predicted by less frequently reported positive affect, such as happiness in older participants with HIV infection [21]. Although interesting, a systematic review of studies using EMA in chronic pain reported that out of 62 included articles, only 16 investigated the relationship between affect and pain intensity [18]. Relevant to the present research, several of these studies indicated a relationship between stress and self-reported pain intensity in patients with fibromyalgia [22] and lower back pain [23]. Moreover, emotional distress was shown to affect pain reports in temporomandibular muscle and joint disorders [24], with mood and stress assuming predictive roles on jaw pain in temporomandibular muscle and joint disorders [25]. Extending these findings, a study on patients with rheumatoid arthritis reported that positive mood in everyday life predicted less momentary pain, while more negative mood in everyday life predicted more pain-related restrictions intensity and depressive symptomatology predicted more momentary pain and more restrictions [26]. Similarly, a recent study combining the data of 3 EMA studies in various samples suffering from rheumatological chronic pain reported that higher levels of depressive and anxiety symptoms were observed in participants whose pain intensity reports were more strongly associated with self-reported affects in everyday life [7].

Taken together, these studies suggest a relationship between affects and pain intensity in everyday life, with the largest part of the studies investigating the relationship between stress and depressive symptomatology, suggesting that both can exacerbate the intensity of pain in daily life. To our knowledge, few studies have investigated the role of pleasant versus unpleasant affects in daily life on pain reports, and this was performed in specific samples only (for instance, rheumatoid arthritis [7]). With the introduction of the new category of chronic primary pain in the ICD-11 [12], the investigation of potential differences between patients with primary and secondary chronic pain with regard to the relationship between pain intensity and affects in everyday life might bring a better understanding of pain perception in patients with primary pain conditions. In that context, it might be interesting to also explore the role of anxiety on the reported pain experiences of individuals with primary pain conditions in daily life. In this study, we asked individuals with chronic pain (primary vs secondary) to report their experienced pain intensity and momentary affect four different times a day, for two consecutive weeks. We expected higher pain intensity in individuals with primary compared to secondary pain. We also expected higher pain intensity in association with negative vs positive affect, which would be stronger for primary vs secondary pain. Because depressive and anxiety scores were available, we explored the relationship between pain intensity with these variables.

2.1. Participants

We included a sample of 16 participants (13 women), with 10 participants with primary pain and 6 with secondary pain. The participants were selected from an ongoing study on the investigation of daily life experiences of chronic pain patients and represent a sub-sample of the original study including only patients with primary or secondary chronic pain disorders. The primary chronic pain group included patients with migraine (N = 3), fibromyalgia (N = 5), hyperlaxity syndrome (N = 1), and lower back pain (N = 1). The secondary chronic pain group included patients with polyarthritis (N = 2), other rheumatological diseases (N = 3), and herniated discs (N = 1). They were recruited over a period of two years from the general public through advertisement, flyers, and word of mouth. Inclusion criteria were: being older than 18 years of age, having received a medical diagnosis of chronic pain, and suffering from chronic pain for more than 3 months. We excluded participants with a condition potentially leading to a fatal issue (e.g. cancer) as this could influence the everyday life affects.

A description of the sample and of the clinical scores are presented in Table 1. Both groups of participants (primary versus secondary chronic pain) did not differ in age or pain duration. No group differences were found for the Beck Depression Inventory (BDI) and Trait Anxiety Inventory (STAI) scores. All patients were taking regularly pain medication (mostly nonsteroidal anti-inflammatory drugs, 1 participant was using opioids). In the primary pain condition group, 3 fibromyalgia participants were taking antidepressants. In the secondary pain condition group, 2 participants were taking immunosuppressive drugs.

Table 1

participant’s description
Variable	Primary Pain	Secondary Pain	Omnibus Test
N	10	5	-
Age in years, mean (SD)	42.6 (16.7)	50.2 (10.8)	F = 0.846 p = 0.373^a
Women, number (%)	10 (83.3)	3 (60)	p = 0.537^b
Pain duration in years, mean (SD)	15.2 (9.94)	12.6 (12.8)	F = 0.202 p = 0.660^a
Trait Anxiety Inventory (STAI) [28]	50.5 (4.11)	47.8 (5.17)	F = 1.317 p = 0.270^a
Beck Depression Inventory (BDI) [27]	15.5 (13)	13.4 (9.76)	F = 0.106 p = 0.749^a
Note: p-values are comparisons between groups via ^aone-way ANOVA and ^bFisher’s Exact tests

2.2. Procedure

The study was approved by the local ethics committee and conducted in accordance with the current legislation and with the Declaration of Helsinki. Participants were thoroughly informed orally and in written about the study and signed an informed consent before participation.

In a first screening interview performed by trained graduate students in clinical and health psychology, participants gave information about their medical history and were instructed about the study. Self-report questionnaires on depressive symptomatology, and anxiety were filled in at home using on online survey tool. Participants were instructed to fill in a paper pain diary during 2 consecutive weeks at least 3 times a day within fixed time periods (morning, afternoon and evening). For each recording, they had to indicate the exact time of the recording, the localization of pain (with the possibility to indicate several body regions), the pain intensity and their current affects.

2.3. Self-report questionnaires

We used the Beck Depression Inventory (BDI) [27] to assess depressive symptomatology, [28]. The BDI is a 21-question multiple-choice self-report inventory, one of the most widely used psychometric tests for measuring the severity of depression. The 21 symptoms and attitudes contained in the BDI reflect the intensity of the depression; items receive a rating of zero to three to reflect their intensity and are summed linearly to create a score which ranges from 0 to 63. Cut-off scores to be used with affective disorder patients: scores from 0 through 9 indicate no or minimal depression; scores from 10 through 18 indicate mild to moderate depression; scores from 19 through 29 indicate moderate to severe depression; and scores from 30 through 63 indicate severe depression. Trait anxiety was measured with the State-and-Trait Anxiety Inventory (STAI) that assesses both state and trait anxiety separately. Each type of anxiety has its own scale of 20 different questions that are scored. Scores range from 20 to 80, with higher scores correlating with greater anxiety.

2.4. EMA assessment

We report here only the EMA measures related to pain intensity and current affects. Pain intensity was evaluated with one item related to the momentary perception of pain intensity that was rated on scale from 1 to 10 (1: the least imaginable pain intensity; 10: the worst imaginable pain intensity). To measure their momentary affects, participants were asked to evaluate whether the following descriptions of their affective state was present or not: sad, happy, depressed, enthusiastic, angry, relaxed, unlucky, glad, annoyed, calm, resigned, and anxious. For each reported mood, participants reported the affective valence related to it on a scale of 1 to 9.

3.1. Main analyses

We ran a mixed model analysis using the overall reported pain intensity (56 reports per participant over two weeks) as dependent variable, including group (primary; secondary) and affect (positive; negative) as fixed factors. We created an index for positive affects (happy, enthusiastic, relaxed, glad, and calm) and for negative affects (sad, depressed, angry, unlucky, annoyed, resigned, and anxious). Subjects were included as random factor. IBM SPSS Statistics 22 (IBM Corp., Armonk, NY, 206 USA) was used for the mixed model analyses.

3.2. Exploratory analyses

To explore the potential relationship between reported pain intensity and affect, we investigated Pearson’s correlations between depressive symptoms (BDI), trait anxiety (STAI) and momentary affective valence in each group using R [29].

4.1. Main analyses

We found a trend towards significance for group (F_{(1, 29.351)} = 3.459, p = 0.073) and a significant effect of affect (F_{(2, 535.719)}, p < 0.001) for pain intensity (Fig. 1). Pairwise comparisons revealed that individuals in the primary pain group tended to report higher pain intensity (M = 4.74, SD = 1.69) than individuals in the secondary pain group (M = 4.25, SD = 1.92). Furthermore, independently of group, individuals reporting more positive affect significantly reported lower pain intensity (estimate = -1.296, SE = 0.161).

4.2. Exploratory analyses

We further explored correlations between reported pain and depressive symptoms (BDI), trait anxiety (STAI), and momentary affective valence. Correlations of pain intensity and depressive symptoms (r = 0.78, p = 0.004), and pain intensity and affective valence (r = -0.84, p = 0.001) were only correlated for the group with primary pain, but not secondary (depressive symptoms r = 0.61, p = 0.270; affective valence r = 0.42, p = 0.490). For the trait anxiety measure, a trend was found for the secondary (r = 0.83, p = 0.085), and not for the primary group (r = 0.33, p = 0.320). See Fig. 2 for more details.

The aim of this pilot study was to investigate the association between pain intensity and affects in the daily life of chronic pain patient with a specific focus on primary versus secondary chronic pain conditions.

Although only approaching significance, individuals in the primary pain group tended to report higher pain intensity levels than individuals in the secondary pain group. Interestingly, independently of group, individuals reporting more positive affect significantly reported lower pain intensity. These results are in line with a previous study on patients with rheumatoid arthritis that showed that positive mood in everyday life predicted less momentary pain [26]. The lack of differences between groups with regard to depressive symptoms and to anxiety levels can be explained by the small sample size as these measures were performed only once (see Table 1). In addition, 3 participants with fibromyalgia were taking antidepressant therapy, what might have influenced the depression scores, in particular as depressive symptoms are particularly frequent in this specific pain condition [30]. The trend for higher self-reported pain intensity in the primary pain group needs to be replicated in larger studies to test its reliability, but might suggest differences in the perception of pain between primary and secondary chronic pain patients.

Our exploratory analyses with regard to correlations between pain intensity and affective states indicated significant associations between depressive symptoms and pain intensity as well as between pain intensity and affective valence only in the group with primary pain. Although very preliminary, these results suggest a specific importance of momentary affects on the perception of pain in daily life of patients with primary chronic pain. These findings are also in line with previous studies reporting an association between stress and self-reported pain intensity in fibromyalgia patients [22] and lower back pain patients [23] for instance. It is also interesting to note that a statistical trend was only found for the association between trait anxiety and pain intensity in the secondary chronic pain group. The association between anxiety scores and perceived pain in daily life has received little attention so far. Should this association stand further empirical investigation in larger groups, it could indicate that affective states also play a role in the perception of pain in secondary pain conditions.

One main limitation of the study is the sample size which gives an exploratory value to the results. However, thanks to the EMA methods, we could gather an interesting number of records per person with regard to pain intensity and affects in daily life. Another limitation is the use of a paper version and not a digital pain diary as we could not control for the actual time of the reporting. The use of a paper-pencil version was motivated by our expectation to include older participants that might have felt less comfortable with a digital diary.

The strength and originality of this study is the comparison of chronic patients according the new ICD-11, taking into account the new category of primary chronic pain conditions, in which affective processes are postulated to play an important role. A further strength is the use of the EMA method which allows measures in the natural environment and over time, increasing the ecological validity of the results and reducing memory bias.

Taken together, the objective of this study was to investigate group differences in self-reported pain intensity and affect in daily life in individuals with primary and secondary chronic pain conditions. Participants filled in paper pain diaries four different times a day, for two consecutive weeks to assess self-reported pain intensity and momentary affect. Self-report questionnaires were used to collect depressive symptomatology and anxiety. In line with our hypothesis we found a trend for individuals in the primary pain group to report higher pain intensity compared to individuals with secondary pin. As expected, positive affect was associated with lower pain intensity. However, groups did not differ with regard to depressive symptoms and trait anxiety.

In conclusion, the preliminary results of this pilot study replicate on one hand the beneficial effect of positive momentary affects on pain intensity in daily life. This is an important information for providing pain management strategies, which could also target mood in everyday life. For instance, cognitive-behavioral therapy working on the shifting of attention towards pleasant feelings or interventions providing chronic pain patients with strategies to increase their ability to savor, e.g. as the Mindfulness-Oriented Recovery Enhancement program [31, 32] might be helpful in that context. On the other hand, our preliminary findings suggest that depressive symptomatology and momentary affects specifically influence the perception of pain in primary pain conditions, extending the literature and providing first evidence for a specific association between pain perception and mood in the daily life of patients with chronic primary pain.

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Research funding: The study was founded by the University of Fribourg Research Funds.

Author’s contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

Competing interests: Authors state no conflict of interest associated with this publication.

Informed consent: Informed consent has been obtained from all individuals included in this study.

Ethical approval: Research involving human subjects complied with all relevant national regulations, institutional policies and is in accordance with the tenets of the Helsinki Declaration (as amended in 2013) and has been approved by the ethical committee of the canton Vaud Switzerland PB_2017_00479)

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No competing interests reported.

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Interactions between self-reported pain intensity and affects in daily life: a pilot study comparing individuals with chronic pain with primary and secondary pain disorders

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Abstract

Figures

1. Introduction

2. Materials And Methods

2.1. Participants

2.2. Procedure

2.3. Self-report questionnaires

2.4. EMA assessment

3. Data Analyses

3.1. Main analyses

3.2. Exploratory analyses

4. Results

4.1. Main analyses

4.2. Exploratory analyses

5. Discussion

Declarations

References

Additional Declarations

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