Emotion Regulation in Pain : Developing Effective Interventions for Patients with Pain and Emotional Distress

Abstract: Chronic pain and emotional problems are common, often co-occur, and result in substantial suffering and social costs. Cognitive Behavioral Therapy (CBT) is a family of treatments that have been extensively studied and has empirical support for its effectiveness in treating both conditions. However, CBT show small benefits for patients with comorbid pain and emotional disorders, and treatments are mostly adapted for one condition or the other. Hence, there is a need for transdiagnostic interventions, targeting both problematic pain behaviors and emotional components. In this thesis, I present results from three experimental studies investigating possibilities to refine and enhance CBT for chronic pain patients with emotional distress by using emotion regulation strategies and skills training from mindfulness-based interventions.In Study I the aim was to evaluate the efficacy of a tailored transdiagnostic hybrid treatment, integrating basic CBT principles with strategies from Dialectical Behavior Therapy (DBT), an acceptance and mindfulnessbased approach developed for individuals with difficulties regulating emotional responses. The hybrid treatment was compared in a randomised controlled trial to an internet-delivered active control condition (iCBT). Intentto- treat analyses showed that the hybrid treatment had positive long-term effects 9 months after treatment on outcomes such as pain interference and symptoms of depression compared to the control condition. We concluded that the hybrid treatment may be considered an acceptable, credible, and efficacious treatment approach.In Study II the aim was to investigate the importance of hypothesized treatment processes of the hybrid treatment, specifically pain-related dysregulation (catastrophizing, fear-avoidance, and non-acceptance of pain), and general emotion dysregulation (difficulties to regulate a wider range of emotional responses). Mediation analysis within the framework of structural equation modelling (SEM), using the full intention-to-treat sample, showed that decreased pain-related dysregulation mediated the effects of the hybrid treatment on both pain interference and symptoms of depression. Furthermore, indirect effects through pain-related dysregulation were more evident for participants scoring higher on this variable at baseline. In addition, decreased general emotion dysregulation mediated effects on symptoms of depression. We concluded that these findings provided further support for the conceptual principles of the hybrid treatment.The aim of Study III was to investigate the effects of components of mindfulness-based interventions, specifically looking at the importance of attentional focus during mindfulness exercises on experiences of experimentally induced pain using the Cold Pressor Test (CPT). In a mixed experimental design, healthy participants were randomly assigned to brief mindfulness exercises with internal focus (body scan), external focus (mindful listening), or a control group using spontaneous coping. Compared to spontaneous coping the mindfulness exercises had positive effects on pain tolerance, pain threshold, pain unpleasantness, frequency of negative thoughts, and belief in thought content during the CPT. While our results showed that changes in attentional focus were consistent with the experimental manipulation, no significant differences were found between internal and external focus on any outcome measure. We concluded that the results did not support the notion that attentional focus would be essential for benefits of mindfulness, and that exercises with both external and internal focus could be beneficial when coping with pain.In conclusion, the results from these studies support integrating basic CBT principles with emotion regulation strategies and skills training from mindfulness-based approaches to enhance treatments for patients with chronic pain and emotional distress. In addition, our findings provide some insights for future research regarding the importance of targeting pain-related dysregulation, and the possibilities of using mindfulness exercises with different attentional focus.