Pain is the unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain can cause an aversive physical and emotional state. Anxiety and anger are emotional states that serve as a protective function in response to pain, which motivate individuals to escape immediate threat. However, when pain is experienced chronically (i.e., for more than 3 months), emotional states can persist, leading to inappropriate and potentially harmful behavioural and cognitive adaptations that increase one’s vulnerability to stress, anxiety, depression and other mood disorders. These changes can hinder the management of pain. Positivity, or positive affect on pain, is an important management strategy that can vastly improve clinical outcomes in patients presenting with pain.
What is positivity in a clinical sense?
Positivity refers to a state that is characterised by pleasant moods or emotions that promote approach-related behaviours, or pleasant moods or emotions that encourage a sense of relaxation, contentment or serenity. In the clinical sense, positivity is an emotional state with both mental and physical characteristics, which aims to promote the improvement of clinical outcomes.
How does positivity work on reducing pain?
Several hypotheses on the mechanism of positive effect reducing pain exist in the literature. One of the more accepted hypotheses is that is reverses cognitive narrowing (i.e., reduces narrow-mindedness) by facilitating access to higher-level associations and a wider range of ideas and sensory information. This hypothesis has been tested in several observational, experimental, and clinical studies, which demonstrate that positive emotions result in expanded attention and enhanced problem solving.
A consequence of broadened cognitive processing is that individuals are able to provide flexible responses to situational challenges (e.g., those presented by the need to adapt to chronic pain) by promoting new behaviours. In this way, positivity expands concepts on thought-action and enhances the development of intra- and interpersonal resources (e.g., psychological resilience, social connectivity and physical health).
What types of interventions aim at improving positivity?
The three most widely researched and supported psychosocial interventions aimed to improve positive effect in chronic pain patients are cognitive-behavioural therapy for pain (CBT-P), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR).
- CBT-P. Has an emphasis on relaxation, positive reappraisal, benefit finding and scheduling of positive activities.
- ACT. Has an emphasis on psychological flexibility and promotoes positivity through encouraging activity engagement and pursuit of goals. As ACT is a value-based intervention, patients should feel more energetic and happier.
- MBSR. Puts emphasis on calmness in difficult situations and present-focused awareness. Like ACT, patients may experience positive emotions such as calmness following MBSR, but they may be just as likely to take away from the MBSR experience a primary state of non-judgement of negative events/appraisals, which may not be correlated with positive emotional state.
The influence of positivity on pain
There is accumulating evidence suggesting that social factors should be considered in analysing the role of positivity in chronic pain. In a recent study on 82 patients with rheumatoid arthritis and 88 patients with osteoarthritis found those who had higher positive social engagement and general positivity were more psychologically resilient and experienced less pain.
Positivity may also arise from adaptive social engagements for chronic pain patients. A recent study on patients with fibromyalgia and osteoarthritis showed that daily increases in positive interpersonal events buffered the effect of daily pain on positivity. Furthermore, the study also demonstrated that marital/partner relationship quality predicted increased positivity.
Although there is considerable evidence indicating that stressful psychological events decrease positivity among chronic pain patients, emotional disclosure of those events is associated with an increase in positivity. This evidence suggests that positivity is related to aspects of our social lives, bolstered by healthy relationships, and amplified by the therapeutic resolution of stressful psychosocial events. These factors, in turn, may dampen the experience of pain and buffer individuals from pain-related disability.
How does this translate to clinical settings?
A reasonable conclusion is that positive effect has a diffuse range of benefits for patients with chronic pain. A standard assessment of patient functioning and aspects of positivity should be included in case histories within clinical settings.
Clinicians should be aware of the effects of positivity in chronic pain patients. Multimodal management strategies focusing on improving positive effect states and physical wellbeing are indicated in these cohorts. This can be achieved by constructing personalised, multidisciplinary management plans. Multimodal interventions should be planned alongside mainstream medical care, and should aim to provide pain management (e.g., medication and exercise), psychosocial wellbeing (e.g., interventions targeting positivity like CBT-P), encourage self-management strategies (e.g., aerobic and specific exercises, controlling weight gain, healthy eating etc.), improve activities of daily living and social networking (e.g., involvement in the community and organisations).
At Sydney Spine & Sports Centre (S3C) our clinicians are trained to construct multimodal management plans. Please follow the links to our website for more information about why to see our clinicians, our evidence-based practise and articles of interest.